Free 2814 - Federal

ORA FIELD LABORATORY EQUIPMENT REQUEST
1. REQUESTED ITEMS(S) (List general type of equipment with detailed individual items, part numbers, cost on reverse side.)

2. TOTAL PRICE: = $ 3. EQUIPMENT ESSENTIAL FOR (Enter appropriate code)
1. Absolute Program or Research Need 2. Replacement 3. Efficiency 4. New Technology

4. PROGRAM PRIORITY (Enter appropriate code)
1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. Medical Devices Elemental Analysis Food Microbiology Nutrition Animal Drugs / Tissue Residue Seafood / Acquaculture Drugs (NDA / ANDA; DOD Shelflife) Pesticides / Industrial Chemicals Drugs / Biologics (pre-approval etc.) Food Additives Natural Toxins Filth / Decomposition General Purpose

5. BUILDING ROOM MODIFICATION (If YES, explain in item 6)

YES

NO

6. JUSTIFICATION AND BACKGROUND (Provide summary or abstract with additional in-depth details. Use a separate page if required.)

SIGNATURES / ENDORSEMENTS / RANKING
7. LABORATORY / RESEARCH DIRECTOR DISTRICT DATE PRIORITY

8. DISTRICT DIRECTOR

DISTRICT

DATE

DISTRICT PRIORITY

9. REGIONAL DIRECTOR

REGION

DATE

REGIONAL PRIORITY

FORM FDA 2814

(8/93)

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Created by: PSC Media Arts (301) 443-2454

EF

PURCHASE REQUISITION INFORMATION FOR PREPARATION OF HHS 393
10. MANUFACTURER / ADDRESS 11. QUOTATION / CONTACT / TELEPHONE

12. GSA CONTRACT

YES

NO

CONTRACT NUMBER:

ITEM

QUANTITY

DESCRIPTION

UNIT PRICE

TOTAL

FORM FDA 2814

(8/93)

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