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Sep 01 09 10:18a SG 813- 313 -1606 p.l <br /> tl./CO SimplexGrinnell LP <br /> Fire & 50 Technology Drive <br /> Security <br /> - Westminster, MA 01441 <br /> SimpiexGrinne// (978) 731 - 2500 <br /> AP FAX: (978) 731 - 7756 <br /> Payment Requisition Form <br /> rhis form is to be used onlywhen payment is required and an invoice is not available ( i.e. permits, drawings, bids). If an invoice is <br /> available please go through the standard payment procedures for submitting invoices to accounts payable. <br /> 'lease provide a detailed reason for payment and attach any available back up when submitting request. <br /> Please supply vendor number. If not available, send an email to sg.apinquiry @tycoint.com. Please fill in 'Request for vendor number" in <br /> 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 <br /> number or information on how to have the new vendor setup. <br /> This payment will be made per system payment terms. Exceptions will require additional approval. (RM < $25k or VP > $25k) <br /> Note: Signature cards must be on file with Accounts Payable for all approvers stating their approved dollar limit. <br /> Request Date: 09/01/09 Cost Distribution <br /> m PO Num $ Amt <br /> Requestor: Irma Perdomo o #1 <br /> / , <br /> Email Address: IPerdomo@simplexgrinnell.com a) #2 <br /> c <br /> #3 <br /> Vendor Number: 056313 (.3 #4 <br /> #5 _ <br /> 'ay - Vendor Name: City of Zephyrhills Subtotal $ - <br /> Remit - to Address Line 1: 5335 8th Street Proj Num Ctrl Dist $ Amt <br /> - Remit - to Address Line 2: 0 ° #1 <br /> City / State / Zip: Zephyrhills, fl 33542 0 #2 <br /> #3 <br /> Payment Amount: $125.00 2 #4 <br /> 6 #5 <br /> Need by Date: 08/11/09 Subtotal $ - <br /> Checks will be cut on Tuesdays & Thursdays a Acct Num Dept Dist $ Amt <br /> Reason for Payment: i t #1 62477 652 292 $ 125.00 <br /> Permits for inspections in Zephyrhills, FL for July 2009. ru #2 <br /> m <br /> E #3 <br /> cu #4 <br /> O #5 <br /> • Oefivery Method: U.S. Mail ❑ FEDEX lig Subtotal $ 125.00 <br /> 7 Deliver to District Grand Total $ 125.00 <br /> )istrict Number: 292 <br /> edEx Contact: Scott Brackett Cost Distribution in balance. <br /> Permanent / 1 Per District <br /> -1 Deliver to Vendor Additional Approvals (when applicable) <br /> Vendor Name: <br /> Contact: Print Name: <br /> Mail -to Address Line 1: Title: <br /> :Mail-to Address Line 2: <br /> 'City / State / Zip: • Signature: <br /> Telephone: Date: <br /> Approver (Print Name): s ei_ Print Name: <br /> :Title: i Q s, ,, Title: <br /> Signature: —T � `� �� Signature: <br /> late: %///�9 Date: <br /> IY <br />