Attachment 15 DD Form 1155.pdf

VANTAGEO

27a. QUANTITY IN LUMN 20 HAS BE

RECEIVE

Attachment 15

ORDER FOR SUPPLIES OR SERVICES

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. 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

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

0.00

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. CONTRACTING/ORDERING OFFICER 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

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

INSPECTED

SP4500-21-R-0003

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