Confirmation Of Services Form OS-501.pdf

CONFIRMATION OF SERVICE

OS-501 (3-10)

www.dot.state.pa.us

Date Service Rendered: _______________________________ SAP Vendor Number: ________________________________ Contractor Name: ____________________________________ Address (1): ________________________________________ Phone: ____________________________________________ Address (2): ________________________________________ PURCHASE ORDER # ________________________________ State:______________ Zip Code: ____________________

(Reference line items on purchase order that match the services that were performed.)

Item # Description / Product ID Quantity U.O.M. Unit Price Item Total

Total:

Contractor Signature: ________________________________ Date: _____________

PENNDOT USE ONLY

I certify the services represented by the confirmation of service form above were received satisfactorily. Therefore, I approve payment be made.

I certify that I have entered a Goods Receipt in SAP for this service. (Goods Receipts should be entered within 48 hours per Management Directive 310.31)

Project Manager Signature Date (mm/dd/yyyy)

SRM/R3 Receiver Signature Date (mm/dd/yyyy)