State Form 44516 (R4/12-02) Approved by State Board of Accounts, 2002
ORDER FORM
Ship to Address Bill to Address
Indiana Department of Correction 6075 Lakeside Boulevard Indianapolis, IN 46278 1-800-PEN-2550 317-388-8580
Customer Order #
Contact Person
Contact Person
Order Date
Phone Number
Phone Number
Expected Delivery Date
QTY.
UNIT
CATALOG #
DESCRIPTION
UNIT PRICE
TOTAL PRICE
SUB TOTAL TOTAL PRICE
6% Sales Tax
(if applicable)
If tax exempt, please attach a copy of your tax exemption certificate.
Delivery Charge
(if applicable)
TOTAL
Authorized Signature and Title of Agency Head Price Correct By:
Authorized Sales Representative
Date
Indiana Department of Correction
V206-R2-12/02