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Jul 02 08 04:42p SG "tileD Fire & Security Sil7lplexGrinnell 813-313-1606 p. 1 Simplex Grinnell LP 50 Technology Drive Westminster, MA 01441 (978) 731-2500 AP FAX: (978) 731-7756 Payment Requisition Form This form is to be usedQD.!ywhen payment is required and an invoice is not available ( Le. permits, drawings, bids). If an invoice Is available please go through the standard payment procedures for submitting invoices to accounts payable. Please provide a detailed reason for payment and attach any available back up when submitting request. Please supply vendor number. If not available, send an emaillosg.apinquiry@tycoint.com. Please fill in "Request for vendor number" in the subject line. Reference the full remit-to address in the body of the email. You will receive either a response with the current vendor number or information on how to have the new vendor setup. This payment will be made per system payment terms. Exceptions will require additional approval. (RM < $25k or VP > $25k) Note: Signature cards must be on file with Accounts Payable for all approvers stating their approved dollar limit. Request Date: iY;7!f-o.)./DQ I I Requestor: Email Address: Chris Brackett cbrackett@simplexqrinnell Vendor Number: 056313 Pay-to Vendor Name: Remit-to Address Line 1 : Remit-to Address Line 2: City I State I Zip: City of Zephyrhills 5335 8th Street Zephyrhills. fl 33542 Payment Amount: $50.00 Need by Date: 07/02/08 Checks will be cut on Tuesdays & Thursdays Reason for Payment: Permits for fire alarm inspections at Sun Medical Center and Zephyr Haven Nursing Home in Zephyrhills. FL. Delivery Method: U.S. Mail 0 FEDEX L..IJ o Deliver to District District Number: 292 Fed Ex Contact: Scott Brackett Pennanent / 1 Per District U Deliver to Vendor Vendor Name: Contact: MaiHo Address Line 1: Mail-to Address Line 2: City I State / Zip: Telephone: Approver (Print Name): Title: Signature: Date: Cost Distribution Qj PO Num $ Amt "0 #1 1/ L- a OJ #2 (fJ rn #3 ..c EJ #4 :J 0.. #5 Subtotal $ - (j) Proj Num etrl DiS! $Amt 0 #1 U ..Q #2 0 ..., #3 13 ~ #4 (5 #5 Subtotal S - a. Acet Num Dept Dist $ Amt x #1 62477 652 292 $ 50.00 UJ "0 #2 ro Q) #3 ..c Qj #4 > a #5 Subtotal $ 50.00 Grand Total $ 50,00 Cost Distribution in balance. Additional Approvals (when applicable) Print Name: Title: Signature: Date: Print Name: Title: Signature: Date: