Document gDDNEkbx4XqpBZQGQOke05kDa

llhooker REQUEST FOR MLSCF.TJJVNEOUS INVOICE Items I through 11 and 6 are to be completed by person preparing this form Item 12 must be furnished by issuer unless purchasing price is to be used 1 BILL TO ~7iE Oo Q/As*tf ADDRESS / s A/ 6- 7~oas AJ Cg 2 SHIP TO ADDRESS SA-aacB- 3 PAY'T TERMS c=7~ J O 4 DATE </->-'? 3____________ 5___ CHECK ONE ____ Charge Back ____ To Be Replaced ____ Not To Be Replaced ____ Consignment In Return Date ______________ ____ Consignment Out Return Date ______________ ____ No Charge ____ TheiT Property ____ Sale 6 PRESENT LOCATION OF MATERIAL (SEND SHIPPING PAPER TO) TYPE OF TRANSPORT (Check One) CPU _____ UPS Motor Freight Air Express ____ Freight Parcel Post Our Dellvery Their Delivery CHECK IF APPLICABLE Prepaid v/ Collect ____ Prepay & Bill At Cost ___ Insure Value $ ____ Breakable Non Breakable INDICATE ALL AVAILABLE INFORMATION Vendor Code Duns Sold To Pur Req No Pur Order No Invoice Ref No See Our Letter See Your Letter Receiving Slip No Work Order No /ZCs- Aa /// 10 QUANTITY 11 DESCRIPTION/EXPLANATION / /*-/<!_ ~7- 2. ao /Sb-vyV /S& ?6o 6~V 12 13 UNIT PRICE AMOUNT 3/,oy.c> S-gj 33 tvd. J r/<- / i. >o /^cr/1 /3xr V l 14 ACCOUNT TO BE DEBITED Attach additional sheets if more description space is required Forward to the Billing Department^ after approval 60 0007 (1/78) A.'WK'D AS3 (10 liZ'li* Ido 16 17 AcrJAU SH3-, S3 W' 2i Saj - /> <6~rZT /--Qd- (L/^G- a , ' AJ Uf ( sapA2 69^0/ 9-0 ;S 7 49 3-5" 15 ACCOUNT TO BE CREDITED <0 35/ * O- OCC 016042