003/SMUOPS-Form/VIII/2017

PURCHASE REQUISITION
PR. NO : [XXX]
PT SELARAS MEDIKA UTAMA
PUT THIS NUMBER ON ALL DOCUMENTS PERKANTORAN HIJAU ARKADIA
INVOICE AND PACKING LIST. TOWER F, LANTAI 6, UNIT 605
PR DATE : [XX/XX/XXXX] JL LET. JEND TB SIMATUPANG KAV 88.
JAKARTA 12520

VENDOR : (Vendor ID) SHIP TO : [Site ID]

[Name] [Name - enter requestor id]

diisi oleh HO
[Company Name] [Company Name]
[Street Address] [Street Address]
[City, ST ZIP Code] [City, ST ZIP Code]
[Phone] [Phone # - relates to the requestor id]

FOR INFORMATION ON THIS

TERMS OF PAYMENT USED DATE (FOR CONSIGNMENT) DELIVERY DATE
PR, CONTACT

day/mo/yr - day/mo/yr day/mo/yr [free type]

NO ITEM # DESCRIPTION QTY UOM QTY APPROVED

Rp -

1. Please notifiy us immediately if you are unable to ship as SUBTOTAL Rp -

specified. DISCOUNT Rp -
2. Please send copy of the Delivery Order to Headquarter after
acknowledgment of receipt at the delivery address TOTAL BEFORE TAX Rp -
3. Send all correspondence to the designated contact person above or
to : purchasing@selarasmed.com TAX Rp -

TOTAL Rp -

VENDOR'S ACCEPTANCE PREPARED BY APPROVED BY

SIGNATURE

NAME
DATE
EMPLOYEE PURCHASING HEAD OF DEPARTMENT