Purchase Order Modification Request Form
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PURCHASING &
CONTRACTS
PURCHASE ORDER MODIFICATION REQUEST FORM
Please fill out form completely and fax to Purchasing at 895-3859
DO NOT SEND ORIGINAL FORM IF FAXED TO AVOID DUPLICATION
Requestor: _________________________________________________ Date _____________
Department: ______________________ Phone: ___________________ M/S: _____________
____________________________________________________________________________
Signature (Must have signature authority on the account)
________________________
_________________________________________
Purchase Order Number
Vendor Name
ACTION REQUIRED: (Please Choose One)
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Cancel Order in its Entirety /Disencumber Funds
Modify Purchase Order
CHANGE REQUESTED:
(Use this box for line #____ of Purchase Order)
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Increase
Decrease
Change Account Line
Add Account Line
Line Item No: _______
Quantity: _____
Unit of Measure: ______
Dollar Amount: ______________________ Account Line: ___________________________________
_____________________________________________________
Reason for Change:
:
CHANGE REQUESTED
(Use this box for line #____ of Purchase Order)
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Increase
Decrease
Change Account Line
Add Account Line
Line Item No: _______
Quantity: _____
Unit of Measure: ______
Dollar Amount: ______________________ Account Line: __________________________________
Reason for Change: ________________________________________________________________
Purchase Order Total Amount after Modification has been completed: ______________________
If necessary, please attach another sheet for additional account lines or explanation of changes.
PURCHASING USE ONLY
Approved by:
Modified by:
Buyer’s Initials: __________ Date __________
Tech’s Initials__________
Date ____________
Director’s Initials: __________ Date __________ (For dollar amounts exceeding bidding threshold.)
Comments: ____________________________________________________________________________
______________________________________________________________________________________
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Reprint PO
Send Revised PO to Vendor
Contact Vendor via Fax or Phone
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Parent category: Business