Attachment_15_DD_Form_1155.docx
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- Attached to
- Scrap Disposal - Japan Federal contract opportunity
- Solicitation number
- SP4500-19-R-0016
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Attachment 15 DD 1155
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Attachment 15
ORDER FOR SUPPLIES OR SERVICES
SP4500-19-R-0016
Japan Scrap
PAGE 1 OF
1. CONTRACT/PURCH OROER/AGREEMENT NO. 2. OELIVERY OROER/CALL NO, 3. OATE OF OROER/CALL 4. REQUISITION/PlJRCH REQUEST NO. 6. PRIORITY
/YYYYMMMDDJ
6. ISSUEO BY CODE I 7. AOMINISTEREO BY /1/ o//Jet //Jan 61 CODE I S. DELIVERY FOB
OESTINAT!ON OTHER
/See Schedule if other)
9. CONTRACTOR COOEI FACILITY I 10. DELIVER TO FOB POINT BV ID•le/ 11, X IF BUSINESS IS
)/YYYYMMMDD/ >--
SMALL
12. (
VANTAGEO
| )DISCOUNT TERMS | SMALL DISAO- |
| NAME | f--------- |
| AND | WOMEN-OWNED |
ADDRESS
13. (
)MAIL INVOICES TO THE ADDRESS IN BLOCK
14. SHIP TO coDel 16,PAVMENT Will BE MADE BV CODE I MARK All PACKAGES AND PAPERS WITH IOENTIFICATION
NUMBERS IN BLOCKS 1 AND 2.
16. DELIVERY/ This delrlery or-de,tca-1-1 is i8-5Ued on another Government .agency or in ac.,c;:ordanc.e with .and s1Jbjact to terms &rtd condrHo-n.s. of abova numbered -contract.
CALL
TYPE
OF Rolotoll<>o you, furnish the following on term5; specified hereln.
ORDER
n
PURCHASE ACCEPTANCE. THE CONTRACTOR HERE8V ACCEPTS THE OFFER REPRESENTED 8Y THE NUMBERED PURCHASE OROER AS IT MAV PREVIOUSLY HAVE BEEN OR IS NOW MODIFIED, SU8JECT TO All OF THE TERMS ANO CONOITIONS SET FORTH, ANO AGREES TO PERFORM THE SAME.
NAME OF CONTRACTOR SIGNATURE TYP!'O NAME ANO TITLE OATE SIGNED
(YYYYMMMDD)
If this box: is markedi suppner must sign Ac-ceptance and r-eturn 1ha foUowing number af coples
17. ACCOUNTING AND APPROPRIATION DATA/LOCAL USE
20. QUANTITY 21. 22. UNIT PRICE 23. AMOUNT
16. ITEM NO. 19, SCHEOULE OF SUPPLIES/SERVICES OROEREO/ ACCEPTED•
UNIT
0.00
| "If qr;antity accepted by the Government is | 24. UNITED STATES OF AMERICA | 26. TOTAL | 0.00 |
| same as quantify ordered; indicate by X. | 26. | ||
| If different,,· enter actual quantity accepted be!a\'r | DIFFERENCES | ||
| quantity ordered snd encitcle. | av, | CONTRACTING/ORDERING OFFICER |
27a. QUANTITY IN COLUMN 20 HAS BEEN
INSPECTED
RECEIVED
| )n | n | |
| b, SIGNATURE.OF AUTHORIZEO GOVERNMENT REPRESENTATIVE | c. DATE | d, PRINTED NAME ANO TITLE OF AUTHORIZED GOVERNMENT |
| {YYYYMMMOD) | REPRESENTATIVE |
e. MAILING ADDRESS OF AUTHORIZED GOVERNMENT REPRESENTATIVE 28. SHIP. NO. 29. D.O. VOUCHER NO. 30. INITIALS
I
| )PARTIAL | 32. PAID 8V | 33. AMOUNT VERIFIED CORRECT FOR | |
| f. TELEPHONE NUMBER | g, E-MAIL ADDRESS | FINAL | |
| 31. PAYMENT | 34. CHECK NUMBER | ||
| 36. I CERTIFY THIS ACCOUNT IS CORRECT ANO PROPER FOR PAYMENT. | COMPLETE | ||
| a, DATE | b. SIGNATURE AND TITLE OF CERTIFYING OFFICER | PARTIAL | 35. l!ILl OF LADING NO. |
(YYYYMMMDDJ
FINAL
| 37, RECEIVED |
| 38. RECEIVED BV /Print! |
| 39. DATE RECEIVED |
| 40. TOTAL CON· |
| 41, SIR ACCOUNT NUMBER |
| 42. Sill VOUCHER NO, |
AT
| (YYYYMMMOD/ |
| TAINERS |
DD FORM 1155, DEC 2001 PREVIOUS EDITION IS OBSOLETE, Adobe Professional 8.0
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