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OFFICE ESSENTIALS AND NON STOCK REQUISITION

ACCOUNT NAME:________________________ REQUESTOR:___________________________ DEPARTMENT:__________________________ P.O. NUMBER_________DATE:____________

PLEASE PRINT THIS ORDER FROM AND MAIL TO THE ADDRESS ABOVE OR FAX TO: 434-392-3655

ITEM CODE	QTY.	MV	DESCRIPTION	PRICE	RECEIVED	B.O.C.

REQUESTOR:___________________________