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19CE2019P0367

ORDER FOR SUPPLIES OR SERVICES

IMPORTANT: Mark all packages and papers with contract and/or order numbers. PAGE OF PAGES
Page 1
1. DATE OF ORDER 2. CONTRACT NO.(If any) 6. SHIP TO:
21 Mar 2019 19CE2019P0367, COLOM
3. ORDER NO. 4. REQUISITION/REFERENCE NO. a. NAME OF CONSIGNEE
19CE2019P0367 PR8071932 ATTN: GSO

5. ISSUING OFFICE (Address correspondence to) b. STREET ADDRESS

AMERICAN EMBASSY COLOMBO 210 GALLE ROAD
210 GALLE ROAD ATTN: GSO PROCUREMENT
COLOMBO, c. CITY d. STATE e. ZIP CODE
COLOMBO
Contact Name: Sam Daniel
Phone: 94-11- 2498614 f. SHIP VIA
Email: DanielSG@state.gov
7. TO: 8. TYPE OF ORDER

a. NAME OF CONTRACTOR CONTACT PHONE NUMBER a. PURCHASE ORDER b. DELIVERY ORDER -- Except for billing
HEMANTHA MAPATUNA 2932109 REFERENCE YOUR: _______ instructions on the reverse, this delivery order
is subject to instructions contained on this side
DUNS NUMBER E-MAIL:
FAX: Please furnish the following on the terms and conditions only of this form and is issued subject to the
123456787 specified on both sides of this order and on the attached sheet, terms and conditions of the above-numbered
2931550 if any, including delivery as indicated. contract.

b. COMPANY NAME
UNITED TRACTORS & EQUIPMENT (PVT) LTD
Legal Name: UNITED TRACTORS & EQUIPMENT (PRIVATE) LT

c. STREET ADDRESS
683, NEGOMBO ROAD, MABOLA

d. CITY e. STATE f. ZIP CODE 10. REQUISITIONING OFFICE

WATTALA AMERICAN EMBASSY COLOMBO
ATTN: GSO
9.ACCOUNTING AND APPROPRIATION DATA
1900-2019--19___X45190001-5688-
SCA-568801-6143-19CE2019P0367-2586-------- $2,513.37USD

Funds Certification Officer Signature:

11. BUSINESS CLASSIFICATION (Check appropriate box(es)) 12. F.O.B. POINT

a. SMALL b. OTHER THAN SMALL c. DISADVANTAGED Destination
d. WOMEN-OWNED e. HUBZone f. SERVICE-DISABLED VETERAN-OWNED
g. WOMEN-OWNED SMALL BUSINESS (WOSB) ELIGIBLE UNDER h. EDWOSB
THE WOMEN-OWNED SMALL BUSINESS PROGRAM
13. PLACE OF 14. GOVERNMENT B/L NO. 15. DELIVER TO F.O.B. POINT ON OR BEFORE (Date) 16. DISCOUNT TERMS
a. INSPECTION b. ACCEPTANCE 31 Mar 2019

17. SCHEDULE (See reverse for Rejections)

ITEM NO. SUPPLIES OR SERVICES QUANTITY UNIT UNIT PRICE AMOUNT QUANTITY ACCEPTED
(a) (b) ORDERED (d) (e) (f) (g)
(c)

SEE LINE ITEM DETAIL

SEE BILLING 18. SHIPPING POINT 19. GROSS SHIPPING WEIGHT 20. INVOICE NO. 17(h) TOT.

21. MAIL INVOICE TO:

(Cont. pages)
INSTRUCTIONS ON
a. NAME
REVERSE
AMERICAN EMBASSY COLOMBO
b. STREET ADDRESS (or P.O. Box) 447,882.11LKR 17(i)
210 GALLE ROAD (GRAND TOTAL)
ATTN: FMO-BILLING
c. CITY d. STATE e. ZIP CODE
COLOMBO
22. UNITED STATES OF AMERICA BY (Signature) 23. NAME Typed
Thomas A Bryant

TITLE: CONTRACTING/ORDERING OFFICER

21 Mar 2019

AUTHORIZED FOR LOCAL REPRODUCTION OPTIONAL FORM 347(REV. 9/2012)

PREVIOUS EDITION NOT USABLE Prescribed by GSA/FAR 48 CFR 53.213(f)
 Page: 2 of 2          
19CE2019P0367

ORDER FOR SUPPLIES OR SERVICES PAGE NO.

SCHEDULE - CONTINUATION
IMPORTANT: Mark all packages and papers with contract and/or order numbers.
DATE OF ORDER TITLE CONTRACT NO. ORDER NO.
21 Mar 2019 Replace worn out wheels of Toyota Reach Truck 19CE2019P0367

ITEM NO. SUPPLIES OR SERVICES QUANTITY UNIT UNIT PRICE AMOUNT QUANTITY
(a) (b) ORDERED (d) (e) (f) ACCEPTED
(c) (g)

0001 Replace worn out wheels of Toyota Reach Truck 1.00 each 420,000.00LKR 420,000.00LKR
(Model# 8BRU18) S/No. 25563

Wheels to be replaced
01, NO, P/NO, 340X250X133 DRIVE WHEEL
Rs,160000/00 (Drive Wheel)
04, NO, P/NO, 127X92X190 LOAD WHEELS
Rs.144000/00 (Load wheels)
02, NOS P/NO, 180X70 CASTER WHEEL
Rs.116000/00 (Caster wheels)

0002 Labor and transport charges - Rs. 25,810.68 1.00 each 27,882.11LKR 27,882.11LKR

Sundry supplies - Rs. 2071.43

TOTAL CARRIED FORWARD TO 1ST PAGE (ITEM 17h) 447,882.11LKR

AUTHORIZED FOR LOCAL REPRODUCTION OPTIONAL FORM 348 (REV. 9/2012)

PREVIOUS EDITION NOT USABLE Prescribed by GSA - FAR (48 CFR) 53.213(f)