NELSON COUNTY SCHOOL BOARD 84 Courthouse Square PO Box 276 Lovingston, VA  22949 Phone:  (434) 260-7646 ‐‐ Fax:  (434) 263‐7115

Date:  Purchase Order No. Issued:

REQUISITION FOR PURCHASE Account No:

Ship To:

Date Required: Department: Attn:

Qty.

Unit

Item #

Description

Unit Price

Total 

Subtotal Shipping TOTAL ***Vendor:

Certification: I hereby certify that the items specified above are necessary for the use of this department.  Funds are budgeted and available for this purchase.

Requisitioner Signature: Title: Phone:

Purchasing Agent Signature:

Fax:

Date:

***Please complete all required information