DHS Form 700-21.pdf
DHS Form PDF 315 KB Posted
- Solicitation number
- HSCG40-11-R-11005
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DHS Form 700-21 Material Inspection and Receiving Report
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Text version
DATE
1. CONTRACT NO. AND LATEST
MODIFICATION NO.
2. ORDER NO. 3. REPORT NO.
4. MATERIAL AND/OR SERVICES INSPECTED
5. CONTRACTOR
7. MANUFACTURER
8. PLACE OF INSPECTION
DHS Form 700-21 (12/03)
PREVIOUS
16. SUBMITTED
17. REJECTED
18. ACCEPTED
19. QUANTITY ON
22. REMARKS (Use Continuation Sheet for Additional Entries)
23. INSPECTED BY 24. TITLE AND TELEPHONE NUMBER
The materials and/or services listed herein have been inspected or certified test data has been examined, by me or under my supervision. The materials and/or services listed above as accepted conform to contract requirements. Those listed as rejected do not conform and may not be delivered, except as authorized under "Remarks."
25. SIGNATURE AND PRINTED NAME 26. TITLE AND TELEPHONE NUMBER 27. DATE
MATERIAL INSPECTION ACCEPTANCE AND RECEIVING REPORT
DEPARTMENT OF HOMELAND SECURITY
CONTRACT LINE 9.
15. ACCEPTED14. REJECTED
QUANTITY
13. COMPLETED12. STARTED11. READY10. RECEIVED
INSPECTION DATES
ORDER
DATE
20. ACCEPTED TO
21. BALANCE
ITEM NO(S)
(If applicable)
REPORTS REPORT
THIS
DATE
TOTAL TO
REMAINING
6. LOCATION WHERE ITEMS WERE DELIVERED OR
CONTRACTOR PERFORMED
INSPECTION DATES QUANTITY9.
10. RECEIVED 11. READY 12. STARTED 13. COMPLETED 14. REJECTED 15. ACCEPTED
3. REPORT NO.
DEPARTMENT OF HOMELAND SECURITY
MATERIAL INSPECTION ACCEPTANCE AND RECEIVING REPORT (Continued)
DHS Form 700-21 (12/03) Page 2
ITEM NO(S)
(If applicable)
CONTRACT LINE
Material Inspection Acceptance and Receiving Report, December 2003 U.S. Department of Homeland Security, Acquisition Policy and Legislation D:20040317145138- 05'00' D:20051012110539- 04'00'
DATE
1. CONTRACT NO. AND LATEST
MODIFICATION NO.
2. ORDER NO.
3. REPORT NO.
4. MATERIAL AND/OR SERVICES INSPECTED
5. CONTRACTOR
7. MANUFACTURER
8. PLACE OF INSPECTION
DHS Form 700-21 (12/03)
PREVIOUS
16. SUBMITTED
17. REJECTED
18. ACCEPTED
19. QUANTITY ON
22. REMARKS (Use Continuation Sheet for Additional Entries)
23. INSPECTED BY
24. TITLE AND TELEPHONE NUMBER
The materials and/or services listed herein have been inspected or certified test data has been examined, by me or under my supervision. The materials and/or services listed above as accepted conform to contract requirements. Those listed as rejected do not conform and may not be delivered, except as authorized under "Remarks."
The materials and/or services listed herein have been inspected or certified test data has been examined, by me or under my supervision. The materials and/or services listed above as accepted conform to contract requirements. Those listed as rejected do not conform and may not be delivered, except as authorized under Remarks.
25. SIGNATURE AND PRINTED NAME
26. TITLE AND TELEPHONE NUMBER
27. DATE
MATERIAL INSPECTION ACCEPTANCE AND RECEIVING REPORT
DEPARTMENT OF HOMELAND SECURITY
CONTRACT LINE
9.
15. ACCEPTED
14. REJECTED
QUANTITY
13. COMPLETED
12. STARTED
11. READY
10. RECEIVED
INSPECTION DATES
ORDER
DATE
20. ACCEPTED TO
21. BALANCE
ITEM NO(S)
(If applicable)
REPORTS
REPORT
THIS
DATE
TOTAL TO
REMAINING
6. LOCATION WHERE ITEMS WERE DELIVERED OR
CONTRACTOR PERFORMED
INSPECTION DATES
QUANTITY
9.
10. RECEIVED
11. READY
12. STARTED
13. COMPLETED
14. REJECTED
15. ACCEPTED
3. REPORT NO.
DEPARTMENT OF HOMELAND SECURITY
MATERIAL INSPECTION ACCEPTANCE AND RECEIVING REPORT (Continued) DHS Form 700-21 (12/03)
ITEM NO(S)
(If applicable)
CONTRACT LINE
| 9. CONTRACT LINE ITEM NUMBER(S) (If applicable) Line 38 of 38.: |
| 15. Quantity Accepted: |
| 14. Quantity REJECTED: |
| Inspection Dates. 13. Completed Date. Enter 2-digit month, 2-digit day and 4-digit year.: |
| Inspection Dates. 12. Started Date. Enter 2-digit month, 2-digit day and 4-digit year.: |
| Inspection Dates. 11. Ready Date. Enter 2-digit month, 2-digit day and 4-digit year.: |
| Inspection Dates. 10. Received Date. Enter 2-digit month, 2-digit day and 4-digit year.: |
| Date. Enter 2-digit month, 2-digit day and 4-digit year.: |
| 1. CONTRACT NUMBER and Latest Modification Number: |
| 2. ORDER NUMBER: |
| 4. MATERIAL AND/OR SERVICES INSPECTED: |
| 5. CONTRACTOR: |
| 7. MANUFACTURER: |
| 8. PLACE OF INSPECTION: |
| 16. SUBMITTED. PREVIOUS REPORTS: |
| 16. SUBMITTED. THIS REPORT: |
| 16. SUBMITTED. TOTAL TO DATE: |
| 17. REJECTED. TOTAL TO DATE: |
| 17. REJECTED. THIS REPORT: |
| 17. REJECTED. PREVIOUS REPORTS: |
| 18. ACCEPTED. TOTAL TO DATE: |
| 18. ACCEPTED. THIS REPORT: |
| 18. ACCEPTED. PREVIOUS REPORTS: |
| 22. REMARKS (Use Continuation Sheet for Additional Entries) : |
| 23. INSPECTED BY: |
| 24. TITLE: |
| 26. TITLE : |
| 27. DATE. Enter 2-digit month, 2-digit day and 4-digit year.: |
| 25. SIGNATURE. This is a protected field.: |
| 19. QUANTITY ON ORDER: |
| 20. ACCEPTED TO DATE: |
| 21. BALANCE REMAINING: |
| 25. PRINTED NAME: |
| 3. REPORT NUMBER: |
| 6. LOCATION WHERE ITEMS WERE DELIVERED OR CONTRACTOR PERFORMED: |
| 24. Telephone Number: |
| 26. Telephone Number: |
| 3. REPORT NUMBER. Pre filled from page 1.: |
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