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Jun 09 09 11:12a SG tL�GO 91 I N 1 2 2009 I SimpfexGrfnnell LP Fire & v Security Vii 50 Technology Drive f Pf _ Westminster, MA 01441 Situp /excGrinne!/ t „ Ph YrhiliS (978) 731 - 2500 AP FAX: (978) 731 -7756 « ' ent RequisWbn Form I This form is to be used onlywhen payment is required an. - + n'ci c e 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 to sg.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: 06/09/09 Cost Distribution PO Num $ Amt Requestor: Irma Perdomo o #1 Email Address: Ioerdomo@simplexq r1nell.com cu #2 N s #3 Vendor Number: 056313 L_ # o_ #5_ Pay -to Vendor Name: City of Zephyrhills Subtotal $ - Remit -to Address Line 1: 5335 8th Street -.,-,5 , Proj Num Ctrl Dist $ Amt U Remit -to Address Line 2: o #1 City / State / Zip: Zephyrhills, fl 33542 n #2 o Y #3 Payment Amount: $250.00 a #4 #5 Need by Date: 06/09/09 Subtotal $ Checks will be cut on Tuesdays & Thursdays Q Acct Num Dept Dist $ Amt Reason for Payment: L t #1 62477 652 292 $ 250.00 Permits for inspections in Zephyrhills, FL for June 2009. T #2 #3 #4 #5 Delivery Method: U.S. Mail ❑ FEDEX o Subtotal $ 250.00 Deliver to District Grand Total $ 250.00 District Number: 292 FedEx Contact: Scott Brackett Cost Distribution in balance. Permanent / 1 Per District 11 Deliver to Vendor Additional Approvals (when applicable) Vendor Name: Contact: Print Name: Mail -to Address Line 1: Title: Mail -to Address Line 2: City / State / Zip: Signature: Telephone: Date: Approver (Print Name): Danny Prendes Print Name: Title: TSM / Title: Signature: rs, ,./ "/" t -- ' Date: /_9- �. g i' Signature: Date: