STANDARD STATE OF ALASKA REQUISITION NUMBER REQUISITION Department of Military and Veterans Affairs 49000 Army Guard Road UNIT REQUISITION SFY Joint Base Elmendorf-Richardson, Alaska 16 99505 NO. DATE/TIME RECEIVED IN DIVISION NAME AND ADDRESS STANDARD REQUISITION DATE PROCUREMENT REQUESTED F.O.B. POINT DELIVERY DATE FOR PROCUREMENT USE ONLY RECEIVED SOLICITATION REQUESTOR NAME TELEPHONE Internal Req. ASSIGNED TO DATE ASSIGNED BY TYPE NUMBER # DATED SUGGESTED CONTRACTORS - (3) - (INCLUDE NAME, PHONE & COMMENTS D.O. NO. FAX NO., AND EMAIL) 1. DEFAULT SHIPPING 2. DEFAULT BILLING 3. ITEM UNIT DESCRIPTION, PERFORMANCE REQUIRED, INTENDED USAGE NO. OF NOTE: Attach scope of work, specifications, or supporting information as needed. CODE UNIT EXTENDED PRICE PRICE PAGE 1 OF DO NOT ARE FEDERAL FUNDS INVOLVED? YES TOTAL NO  ADDRESS 1 EXCEED $ ALL EVENT TYPE APPR UNIT FUND OTHER PAGES PAGES 1 $ 2 AMOUNT SY ACCT ACTIVITY PROGRAM OBJECT FY NMR IT APPROVAL DIST LIQ TEMPLATE 1 2 Signature 3 4 Date REQUESTER NAME AND TITLE REQUESTER’S SIGNATURE TELEPHONE NUMBER (Printed) PROCUREMENT OFFICER APPROVAL Printed Name and Title Signature Date CERTIFICATION: I certify that the facts herein and on supporting documents are correct, that this voucher constitutes a legal charge against funds and appropriations cited, that sufficient funds are encumbered to pay this obligation, or that there is a sufficient unencumbered balance in the appropriation cited to cover this obligation. I am aware that certifying false, inaccurate or misleading documents constitutes an unsworn falsification under AS 11.56.210. CERTIFYING OFFICER'S PRINTED NAME CERTIFYING OFFICER'S SIGNATURE DATE
STANDARD REQUISITION STATE OF ALASKA Department of Military and Veterans Affairs REQUISITION NUMBER 49000 Army Guard Road UNIT REQUISITION NO. SFY Joint Base Elmendorf-Richardson, Alaska 99505 16 DIVISION NAME AND ADDRESS STANDARD REQUISITION DATE DATE/TIME RECEIVED IN PROCUREMENT REQUESTED DELIVERY DATE F.O.B. POINT FOR PROCUREMENT USE ONLY RECEIVED BY SOLICITATION TYPE REQUESTOR NAME TELEPHONE NUMBER Internal Req. # ASSIGNED TO DATED D.O. NO. DATE ASSIGNED SUGGESTED CONTRACTORS - (3) - (INCLUDE NAME, PHONE & FAX NO., AND EMAIL) COMMENTS 1. 2. DEFAULT SHIPPING 3. DEFAULT BILLING ITEM NO. CODE UNIT OF DESCRIPTION, PERFORMANCE REQUIRED, INTENDED USAGE NOTE: Attach scope of work, specifications, or supporting information as needed. UNIT PRICE EXTENDED PRICE TOTAL ALL PAGES $ ADDRESS ARE FEDERAL FUNDS INVOLVED? NO  YES PAGE 1 OF 1 PAGES DO NOT EXCEED $ EVENT TYPE APPR UNIT FUND OTHER 1 2 AMOUNT SY ACCT TEMPLATE ACTIVITY PROGRAM OBJECT FY NMR IT APPROVAL DIST LIQ 1 2 Signature 3 4 Date REQUESTER NAME AND TITLE (Printed) REQUESTER’S SIGNATURE TELEPHONE NUMBER PROCUREMENT OFFICER APPROVAL Printed Name and Title Signature Date CERTIFICATION: I certify that the facts herein and on supporting documents are correct, that this voucher constitutes a legal charge against funds and appropriations cited, that sufficient funds are encumbered to pay this obligation, or that there is a sufficient unencumbered balance in the appropriation cited to cover this obligation. I am aware that certifying false, inaccurate or misleading documents constitutes an unsworn falsification under AS 11.56.210. CERTIFYING OFFICER'S PRINTED NAME CERTIFYING OFFICER'S SIGNATURE DATE
DMVA%20Standard%20Requisition%20Form%20Version%202.docx