Free 44874.pdf - Indiana

REQUEST FOR PRINT SERVICE
State Form 44874 (R13 / 4-09)

INDIANA DEPARTMENT OF ADMINISTRATION PRINT VENDOR PITNEY BOWES MANAGEMENT SERVICES

Reset Form

FOR OFFICE USE ONLY Date received (month, day, year)

Received by Change order number CUSTOMER INFORMATION
Agency number

PB job number A
Date order changed (month, day, year)

Agency tracking number
Name of agency

Name of department

ACCOUNT INFORMATION
Fund/ Account/ Budget Reference Dept/ Class Program/ Project/ Project Activity

AGENCY REQUESTOR AND AUTHORIZATION
Name of requestor Telephone number Authorized Signature Name of Division Director

JOB INFORMATION
Is this a State Form? Contain a State Seal? yes yes no no yes no
(State Form requests MUST be submitted to ICPR for specifications prior to printing)

Total Originals Is the Original: 1 sided or 2 sided

Quantity Requested

Contain Confidential Information?

(If yes, complete & submit SF 53623 "Confidential Print and Mail Service Submission of Confidential Information")

Is the Original: Color or Black/ White Is the Original: Attached or Description Digital

Require a Proof?

yes

no

A Government Publication?

yes

no

(21 copies will be provided to State Libraries and Archives)

Number of proofs required?

Job Title / State Form number with Revision number

DELIVERY INFORMATION
Pick up. We will contact you. Deliver to: Name of contact Telephone number of contact E-mail address of contact Due Date Due Time Mail code number

Flat sheet

Booklet

Card

Envelope ( size

TYPE OF FORM ) Label ( size DUPLICATION

)

Unit set / Bond set

Other

SIZE COLOR WEIGHT TYPE INK DUPLEX ORIENTATION 3 Ring Punch BINDING STAPLING SHRINK WRAP

8.5 x 11 White

PAPER STOCK 8.5 x 14 11 x 17 Other:

Other: 70 #

8.5 x 11 White

8.5 x 14 Other:

COVER STOCK 11 x 17 Other: Blank Back Cover Other: Color Head to Head Head to Foot

20 # (28#, if color) Other: Bond Carbonless Color Two Sided Landscape Dividers Pad Black and/or One Sided Portrait Collate GBC Tape

18 # carbonless Index Other:

110 # (80 # if color print) Other: Tag Index Wraparound Black and/or Two Sided Landscape ) Half Color Other: Tri ­ Fold No printing

Head to Head

Head to Foot

One Sided Portrait

FINISHING
Numbering (beginning number Number Per Pad Landscape Left FOLDING TABS CUTTING Z- Fold 3 Set 5 Set

Top Left Double Left Saddle Stitch Other: Number per package

Sets Per Book

x

FOR OFFICE USE ONLY

IN

OUT

INITIAL

SPECIAL INSTRUCTIONS:

SETUP PRINTING` FINISHING MAILING SHIPPING Received by: (Customer Signature) Date/ Time

Page 1 of 3

REQUEST FOR PRINT SERVICE
State Form 44874 (R13 / 4-09)

INDIANA DEPARTMENT OF ADMINISTRATION PRINT VENDOR PITNEY BOWES MANAGEMENT SERVICES

SPECIFICATIONS
(insert specific specifications)

Page 2 of 3

REQUEST FOR PRINT SERVICE
State Form 44874 (R13 / 4-09)

INDIANA DEPARTMENT OF ADMINISTRATION PRINT VENDOR PITNEY BOWES MANAGEMENT SERVICES

CHANGE ORDER
INSTRUCTIONS: Please complete this form when making a request for change to a already submitted Pitney Bowes Request for Print Service on State Form 44874 (R13/4-09). As your Change order number, use the PB job number (top right corner of page 1) of the already submitted request. If making changes to the Specifications (page two) please highlight the areas of change. You must notify the Indiana Commission of Public Records (ICPR) of all changes of specifications or artwork involving a state form. Name of agency Telephone number Funding information (If applicable) Check all that apply Specification change Other: Change in contact Change in artwork Other: Other: Other: AGENCY CONTRACT INFORMAL Name of agency contact Fax number Other reference information REASON FOR CHANGE Name of department E-mail address

Please list all applicable changes from above with detail below. Include address details, state form / material numbers, etc. Change 1: Detail:

Change 2:

Detail:

Change 3:

Detail:

Change 4:

Detail:

Change 5:

Detail:

Change 6:

Detail:

Page 3 of 3