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Flug 17 09 03:34p SG 813 313 - 1606 P• tyro • • SimplexGnnnell LP Fire & 50 Technology Drive Security Westminster, MA 01441 SimplexGrinnell (978) 731 -2500 AP FAX: (978) 731 -7756 I Payment Requisition Form I This form is to be used oniywhen 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 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: 08/17/09 Cost Distribution 8 PO Num $ Amt Requestor: Chris Brackett p #1 Email Address: cbrackett(ct)simplexgrinnell a, . #2 to .c #3 Vendor Number: 056313 - #5 Pay - Vendor Name: City of Zephyrhills Subtotal $ - Remit - to Address Line 1: 5335 8th Street m Proj Num Ctrl Dist $ Amt Remit -to Address Line 2: U #1 City / State / Zip: Zephyrhills, fl 33542 , -., #3 U Payment Amount: $25.00 E #4 0 #5 Need by Date: 08118/09 Subtotal $ - Checks will be cut on Tuesdays & Thursdays Acct Num Dept Dist $ Amt Reason for Payment: uj #1 62477 659 292 $ 25.00 !Permit for a kitchen hood inspection at Florida Hospital Zephyrhills in Zephyrhills, N #2 FL. _c #3 > #4 0 . #5 1. Delivery Method: U.S. Mail ❑ FEDEX Subtotal $ 25.00 U Deliver to District Grand Total $ 25.00 District Number: 292 Cost Distribution in balance. Fed Ex Contact: Scott Brackett Permanent / 1 Per District U Deliver to Vendor Additional Approvals (when applicable) Vendor Name: I 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: j i1 1.4, - Signature: Date: 4 4 ai ,Date: _ •