Disaster Receipt Form – Form 6409-B
                                                                                                                                                

DR# (if applicable):     DR Name:        Date:        Requisition # :  
 Requestor Name :
 Signature:
 Title :
 Phone:
Delivery Information
 Site POC Name :    Phone:    Email:  
Address:
 City:    State:  Zip:     
Description of product(s) and/or service(s)
Stock No.
Quantity
Unit of measure
(EA/PK/CS/BX)
Total QTY (each)
Description
Date needed

Notes
{var NOTES}

Acknowledgement by person receiving product(s) and/or service(s).
      I hereby certify that I have received all product(s) and/or service(s) listed above.
 If all product(s) and/or service(s) have not been received, provide explanation in the space below.
Discrepancies:
{var Discrepancies}
 Received by Print Name: {var AKName}
 Received by Signature: {var AKSig}
 Date: {var AKDate}  Time of arrival: {var AKTime}
 Group: {var AKGroup}

DCS JT DMWT Disaster Requisition (F6409) V.2.0 2015.02.13                                                                                      ARC 6509-B v. 0.12