Dd Form 1155 - Order For Supplies Or Services
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1PAGE 1 OF
ORDER FOR SUPPLIES OR SERVICES
3. DATE OF ORDER/CALL
1. CONTRACT/PURCH ORDER/AGREEMENT NO.
2. DELIVERY ORDER/CALL NO.
4. REQUISITION/PURCH REQUEST NO.
5. PRIORITY
(YYYYMMMDD)
CODE
7. ADMINISTERED BY (If other than 6)
CODE
6. ISSUED BY
8. DELIVERY FOB
DESTINATION
OTHER
(See Schedule if
other)
10. DELIVER TO FOB POINT BY (Date)
9. CONTRACTOR
CODE
FACILITY
11. X IF BUSINESS IS
(YYYYMMMDD)
SMALL
SMALL DISAD-
12. DISCOUNT TERMS
VANTAGED
NAME
WOMEN-OWNED
AND
ADDRESS
13. MAIL INVOICES TO THE ADDRESS IN BLOCK
14. SHIP TO
CODE
15. PAYMENT WILL BE MADE BY
CODE
MARK ALL
PACKAGES AND
PAPERS WITH
IDENTIFICATION
NUMBERS IN
BLOCKS 1 AND 2.
DELIVERY/
16.
This delivery order/call is issued on another Government agency or in accordance with and subject to terms and conditions of above numbered contract.
CALL
TYPE
Reference your
furnish the following on terms specified herein.
OF
PURCHASE
ACCEPTANCE. THE CONTRACTOR HEREBY ACCEPTS THE OFFER REPRESENTED BY THE NUMBERED PURCHASE ORDER AS IT MAY PREVIOUSLY HAVE
ORDER
BEEN OR IS NOW MODIFIED, SUBJECT TO ALL OF THE TERMS AND CONDITIONS SET FORTH, AND AGREES TO PERFORM THE SAME.
NAME OF CONTRACTOR
SIGNATURE
TYPED NAME AND TITLE
DATE SIGNED
(YYYYMMMDD)
If this box is marked, supplier must sign Acceptance and return the following number of copies:
17. ACCOUNTING AND APPROPRIATION DATA/LOCAL USE
20. QUANTITY
21.
ORDERED/
18. ITEM NO.
19. SCHEDULE OF SUPPLIES/SERVICES
22. UNIT PRICE
23. AMOUNT
UNIT
ACCEPTED*
$0.00
$0.00
$0.00
24. UNITED STATES OF AMERICA
$0.00
25. TOTAL
*If quantity accepted by the Government is
same as quantity ordered, indicate by X.
26.
If different, enter actual quantity accepted below
DIFFERENCES
quantity ordered and encircle.
BY:
CONTRACTING/ORDERING OFFICER
27a. QUANTITY IN COLUMN 20 HAS BEEN
ACCEPTED, AND CONFORMS TO
INSPECTED
RECEIVED
THE CONTRACT EXCEPT AS NOTED:
b. SIGNATURE OF AUTHORIZED GOVERNMENT REPRESENTATIVE
c. DATE
d. PRINTED NAME AND TITLE OF AUTHORIZED GOVERNMENT
(YYYYMMMDD)
REPRESENTATIVE
30. INITIALS
e. MAILING ADDRESS OF AUTHORIZED GOVERNMENT REPRESENTATIVE
28. SHIP. NO.
29. D.O. VOUCHER NO.
PARTIAL
33. AMOUNT VERIFIED CORRECT FOR
32. PAID BY
f. TELEPHONE NUMBER
g. E-MAIL ADDRESS
FINAL
31. PAYMENT
34. CHECK NUMBER
36. I CERTIFY THIS ACCOUNT IS CORRECT AND PROPER FOR PAYMENT.
COMPLETE
a. DATE
b. SIGNATURE AND TITLE OF CERTIFYING OFFICER
35. BILL OF LADING NO.
PARTIAL
(YYYYMMMDD)
FINAL
38. RECEIVED BY (Print)
37. RECEIVED
39. DATE RECEIVED
40. TOTAL CON-
41. S/R ACCOUNT NUMBER
42. S/R VOUCHER NO.
AT
(YYYYMMMDD)
TAINERS
DD FORM 1155, DEC 2001
PREVIOUS EDITION IS OBSOLETE.
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Parent category: Business