Form Pss-02.2 - Special Order Form - Paperclips Etc.
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PAPERCLIPS Etc.
SPECIAL Orders Form
This form is used to order supplies that are not readily available in the DOE HQ self‐service supply stores or for items
that require approval by Office Management. All supplies ordered MUST be used for Official Government Business only.
Requestor’s Name: ___________________________________________________
Date: __________________
Phone Number: __________________
DOE ID Badge No.: ________________________________________
Catalog Name: ______________________________________________________
Org Code: ______________
Item Number
Page #
Item Description
Quantity
Store Use Only
ALL printed names (legible), signatures and dates are required before your Special order is processed.
Requestor’s Signature:
Date:
Office Director’s Printed Name: __________________________________________
Date: ________________
Signature: ___________________________________________________________
Budget Officer’s Printed Name: __________________________________________
Date: ________________
Signature: ___________________________________________________________
Program’s Resource Manager’s Printed Name: ______________________________
Date: ________________
Signature: ___________________________________________________________
ALL SPECIAL ORDERS ARE SUBJECT TO FULL PAYMENT OR A RESTOCKING FEE WHEN ITEMS ORDERED ARE RETURNED TO
THE SUPPLIER DUE TO THE CUSTOMER NOT PICKING UP THE ITEM(S) WITHIN FIVE DAYS OF RECEIPT BY THE STORE
PERSONNEL OR THE CUSTOMER’S DECISION TO RETURN THE ITEM(S).
Order Received by: Printed Name: __________________________________________________________________
Signature: ______________________________________________________
Date: _________________
PSS‐02.2 (March 7, 2011) Replaces PSS‐02.1
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Parent category: Business