Indiana University Kokomo
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Office of Student Activities

Purchase Requisition Form

* Required fields

1. Information about yourself and the organization

*Student organization name
*Your name
*Your e-mail address
Your title within the organization
*Your daytime telephone number
Your evening telephone number
*Date you need item(s)
(mm/dd/yyyy)

2. Vendor Information

*Name
*Street address
*City, State, Zip
*Telephone
Toll-free telephone (if available)
Fax
*Contact person

Requested Items

Please complete the following information for each item you are requesting.

Note: Total cost = Quantity x Price

Item 1

Quantity
Price per unit
Total cost
Manufacturer's/ item number
Description of item

Item 2

Quantity
Price per unit
Total cost
Manufacturer's/ item number
Description of item

Item 3

Quantity
Price per unit
Total cost
Manufacturer's/ item number
Description of item

Item 4

Quantity
Price per unit
Total cost
Manufacturer's/ item number
Description of item

Item 5

Quantity
Price per unit
Total cost
Manufacturer's/ item number
Description of item

Print a copy for your records before submitting.