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BACKORDER INFORMATION BPA/IDC/TCO SOURCE NO. FSS CONTRACT NO. SHIPPING DATE CLEARANCE REQUIRED YES Date ordered NIH 1861-9 01/13 Date sent to Central Procurement INSTITUTE PURCHASING AGENT COPY DISTRIBUTION White -Administrative Office Canary -Requester s final copy Pink -Requester s interim copy NO. DATE RECEIVED stamp here DIVISION/BRANCH APPROVAL signature Requisition Worksheet ORDER NO. from Delpro System Requester NAME DIV. /BRANCH OBJECT CLASS CODE CUSTODIAL CODE BUILDING/ROOM CAN PHONE NO. DATE NEEDED Source NAME OF COMPANY ADDRESS COMPANY CLERK S NAME Order Information Item No* Backorder CATALOG NUMBER QTY. DESCRIPTION LIST PRICE UNIT OF ISSUE DISCOUNTED TOTAL Total ARE THE ITEMS ORDERED AVAILABLE FROM THESE SOURCES Yes No Yes No 1. NIH Surplus 3. Blind/Severely Handicapped 5. FEDERAL Supply Schedules 2. UNICOR 4. NIH or GSA Stock catalog or store 6. OPEN-MARKET Suppliers COMPANY NAME If order exceeds 2500 2 more sources of supply must be contacted and listed below. AVAILABILITY DATE CALLED JUSTIFICATION Required for all orders large business ADP personal appeal items and sole source. DATE RECEIVED stamp here DIVISION/BRANCH APPROVAL signature Requisition Worksheet ORDER NO. from Delpro System Requester NAME DIV. /BRANCH OBJECT CLASS CODE CUSTODIAL CODE BUILDING/ROOM CAN PHONE NO. DATE NEEDED Source NAME OF COMPANY ADDRESS COMPANY CLERK S NAME Order Information Item No* Backorder CATALOG NUMBER QTY. /BRANCH OBJECT CLASS CODE CUSTODIAL CODE BUILDING/ROOM CAN PHONE NO. DATE NEEDED Source NAME OF COMPANY ADDRESS COMPANY CLERK S NAME Order Information Item No* Backorder CATALOG NUMBER QTY. DESCRIPTION LIST PRICE UNIT OF ISSUE DISCOUNTED TOTAL Total ARE THE ITEMS ORDERED AVAILABLE FROM THESE SOURCES Yes No Yes No 1. DESCRIPTION LIST PRICE UNIT OF ISSUE DISCOUNTED TOTAL Total ARE THE ITEMS ORDERED AVAILABLE FROM THESE SOURCES Yes No Yes No 1. NIH Surplus 3. Blind/Severely Handicapped 5. FEDERAL Supply Schedules 2. UNICOR 4. NIH or GSA Stock catalog or store 6. NIH Surplus 3. Blind/Severely Handicapped 5. FEDERAL Supply Schedules 2. UNICOR 4. NIH or GSA Stock catalog or store 6. OPEN-MARKET Suppliers COMPANY NAME If order exceeds 2500 2 more sources of supply must be contacted and listed below. OPEN-MARKET Suppliers COMPANY NAME If order exceeds 2500 2 more sources of supply must be contacted and listed below. AVAILABILITY DATE CALLED JUSTIFICATION Required for all orders large business ADP personal appeal items and sole source. DATE RECEIVED stamp here DIVISION/BRANCH APPROVAL signature Requisition Worksheet ORDER NO. from Delpro System Requester NAME DIV. /BRANCH OBJECT CLASS CODE CUSTODIAL CODE BUILDING/ROOM CAN PHONE NO. DATE NEEDED Source NAME OF COMPANY ADDRESS COMPANY CLERK S NAME Order Information Item No* Backorder CATALOG NUMBER QTY. DESCRIPTION LIST PRICE UNIT OF ISSUE DISCOUNTED TOTAL Total ARE THE ITEMS ORDERED AVAILABLE FROM THESE SOURCES Yes No Yes No 1. /BRANCH OBJECT CLASS CODE CUSTODIAL CODE BUILDING/ROOM CAN PHONE NO. DATE NEEDED Source NAME OF COMPANY ADDRESS COMPANY CLERK S NAME Order Information Item No* Backorder CATALOG NUMBER QTY. DESCRIPTION LIST PRICE UNIT OF ISSUE DISCOUNTED TOTAL Total ARE THE ITEMS ORDERED AVAILABLE FROM THESE SOURCES Yes No Yes No 1. NIH Surplus 3. Blind/Severely Handicapped 5. FEDERAL Supply Schedules 2. UNICOR 4. NIH or GSA Stock catalog or store 6.

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