DD1155.pdf

14. SHIP TO

ORDER FOR SUPPLIES OR SERVICES

PAGE 1 OF

1. CONTRACT/PURCH ORDER/AGREEMENT NO. 2. DELIVERY ORDER/CALL NO. 3. DATE OF ORDER/CALL

(YYYYMMMDD)

4. REQUISITION/PURCH REQUEST NO. 5. PRIORITY

6. ISSUED BY CODE 7. ADMINISTERED BY (If other than 6) CODE 8. DELIVERY FOB

DESTINATION

OTHER

(See Schedule if other)

10. DELIVER TO FOB POINT BY (Date)

(YYYYMMMDD)

12. DISCOUNT TERMS

13. MAIL INVOICES TO THE ADDRESS IN BLOCK

11. X IF BUSINESS IS

SMALL

SMALL DISAD-

VANTAGED

WOMEN-OWNED

CODE 15. PAYMENT WILL BE MADE BY CODE MARK ALL

PACKAGES AND

PAPERS WITH

IDENTIFICATION

NUMBERS IN

BLOCKS 1 AND 2.

16.

TYPE

OF

ORDER

DELIVERY/

CALL

PURCHASE

This delivery order/call is issued on another Government agency or in accordance with and subject to terms and conditions of above numbered contract.

Reference your furnish the following on terms specified herein.

ACCEPTANCE. THE CONTRACTOR HEREBY ACCEPTS THE OFFER REPRESENTED BY THE NUMBERED PURCHASE ORDER AS IT MAY PREVIOUSLY HAVE BEEN OR IS NOW MODIFIED, SUBJECT TO ALL OF THE TERMS AND CONDITIONS SET FORTH, AND AGREES TO PERFORM THE SAME.

If this box is marked, supplier must sign Acceptance and return the following number of copies:

NAME OF CONTRACTOR SIGNATURE TYPED NAME AND TITLE DATE SIGNED

(YYYYMMMDD)

17. ACCOUNTING AND APPROPRIATION DATA/LOCAL USE

18. ITEM NO. 19. SCHEDULE OF SUPPLIES/SERVICES

20. QUANTITY

ORDERED/

ACCEPTED*

21.

UNIT

22. UNIT PRICE 23. AMOUNT

*If quantity accepted by the Government is same as quantity ordered, indicate by X.

If different, enter actual quantity accepted below quantity ordered and encircle.

24. UNITED STATES OF AMERICA 25. TOTAL

26.

DIFFERENCES

30. INITIALS

27a. QUANTITY IN COLUMN 20 HAS BEEN

INSPECTED RECEIVED ACCEPTED, AND CONFORMS TO

THE CONTRACT EXCEPT AS NOTED:

c. DATE

(YYYYMMMDD)

b. SIGNATURE OF AUTHORIZED GOVERNMENT REPRESENTATIVE

28. SHIP. NO.

PARTIAL

FINAL

31. PAYMENT

COMPLETE

PARTIAL

FINAL

29. D.O. VOUCHER NO.

32. PAID BY 33. AMOUNT VERIFIED CORRECT FOR

34. CHECK NUMBER

35. BILL OF LADING NO.

42. S/R VOUCHER NO.

36. I CERTIFY THIS ACCOUNT IS CORRECT AND PROPER FOR PAYMENT.

a. DATE

(YYYYMMMDD)

b. SIGNATURE AND TITLE OF CERTIFYING OFFICER

37. RECEIVED

AT

38. RECEIVED BY (Print) 39. DATE RECEIVED

(YYYYMMMDD)

40. TOTAL CON-

TAINERS

41. S/R ACCOUNT NUMBER

DD FORM 1155, DEC 2001 PREVIOUS EDITION IS OBSOLETE.

CONTRACTING/ORDERING OFFICER

9. CONTRACTOR CODE FACILITY

NAME

AND

ADDRESS

BY:

d. PRINTED NAME AND TITLE OF AUTHORIZED GOVERNMENT

REPRESENTATIVE

e. MAILING ADDRESS OF AUTHORIZED GOVERNMENT REPRESENTATIVE

f. TELEPHONE NUMBER g. E-MAIL ADDRESS issued_by: NAVAL SURFACE WARFARE CENTER, CARDEROCK

9500 MACARTHUR BLVD

WEST BETHESDA, MD 20817

adminby: VENDOR CERTIFICATION

9500 MACARTHUR BLVD

WEST BETHESDA, MD 20817