The University of Tennessee Health Science Center

Computer Order Request Form

  1. Please complete all information.
  2. Once you have completed the form, you can print the results for faxing. Fax all orders to Lisa Aitken at 448-8478.
Date Order Placed:
UT Contract No.:
Vendor Name:
UT Blanket P.O. No:
Dept. Account Name:
Dept. Account Number:

Department Contact:

Name: Phone No:
Email Address: Fax No.:

Ship To:
Bill To:
Qty: Part No.: Description: Unit Price: Total:
Grand Total

Certification: For any item of equipment costing $1,000 or more, purchased under federal grant: I certify that the appropriate approvals and screening requirements have been complied with. This requirement is % federally funded.
Authorized by:

Note: This form must be signed by the department head or another person who is authorized to obligate the account.

VENDORS: Fax confirmation to department contact and Vic Crutchfield, Purchasing Services, (901) 448-8028.