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"tl./C:O Fire & Security SiIDple.Grinnell SimplexGrinnell LP 50 Technology Drive Westminster, MA 01441 (978) 731-2500 AP FAX: (978) 731-7756 Payment Requisition Form This form is to be used onlvwhen payment is required and an invoice is not available ( i.e. 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 email tosg.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. 08/21 /08 Request Date: Requestor: Email Address: Chris Brackett cbrackett@simolexQrinnell Vendor Number: 056313 Pay-to Vendor Name: Remit-to Address Line 1 : Remit-to Address Line 2: City / State / Zip: City of Zephyrhills 5335 8th Street Zephyrhills, fI 33542 Payment Amount: $25.00 Need by Date: 07/02/08 Checks will be cut on Tuesdays & Thursdays Reason for Payment: Permits for sprinkler inspection at Zephyr Haven Nursing Home in Zephyrhills, FL. Delivery Method: U.S. Mail U FEDEX 0 o Deliver to District District Number: 292 FedEx Contact: Scott Brackett Permanent /1 Per District U Deliver to Vendor Vendor Name: Contact: Mail-to Address Line 1: Mail-to Address Line 2: City / State / Zip: Teleohone: Approver (Print Name): Title: Signature: Date: Cost Distribution L- PO Num $Amt a.l 'E #1 1/ 0 a.l #2 Ul ltl #3 .!: ~ #4 ::l a. #5 Subtotal $ - ...... Proj Num Ctrl Dist $Amt Ul 0 #1 () .0 #2 0 ...., #3 ...... () ~ #4 i:5 #5 Subtotal $ - c. Acct Num Dept Dist $Amt x #1 62477 652 292 $ 25.00 w 'C #2 ltl a.l #3 .!: L- a.l #4 > 0 #5 Subtotal $ 25.00 Grand Total $ 25.00 Cost Distribution in balance. Additional Approvals (when applicable) Print Name: Title: Signature: Date: Print Name: Title: Signature: Date: