ARC FORM 6409
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
Special Instructions :
{var Instructions}
The following information must be filled in by the APROVER ONLY:
Approval includes verification of need; need consistent with Service Delivery Plan and budget.
Approver Name :
{var AproveName}
Signature:
{var AprSig}
Title :
{var APVTitle}
Phone:
{var apvPhone}
Procurement Method (This section is optional) :
Account string to charge:
-
-
-
-
-
Procurement tool to use:
Donation
ReQuest
Concur Invoice
P-card
Transfer
Loan
Other: (Explain) :
{var Explation}
DCS JT DMWT Disaster Requisition (F6409) V.2.0 2015.02.13
ARC 6509 v. 0.12