HomeMy WebLinkAboutPURCHASE ORDER1
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streem-0660
DATE:
Oct. 22, 2018
ATTN:
ATLANTIC ACCESS SCA
BY
FROM:
Gayle Epstein St Lucie Couniv
SUBJECT:
Q92279 MCELANEY CHARLES
Note:
EXP: 10/20
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T PALM BEACH VAMC 548 (648/121)
N. MILITARY TRAIL (548/121)
F PALM BEACH, FL 33410
;HASING AGENT (OA): EPSTEIN,GAYLE S
Phone: 561-722-8726 , Fax: 407-975-7901
Entail: gayle.epstein@va.gov
To: BESA CONSTRUCTION From: WEST PALM BEACH VAMC 5
Fax: 561 847-3218 Pages: 4
Phone: 561-847-3218 Date & Time: 10/22/2018 1:26:20 PM
Re: Purchase Order - MCELANEY,CHARLES H, 772-801-5995
PO #: 548-Q92279
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To obtain credit card information call purchasing agent.
Comments:
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OMB Number 2900-0188 PO#: Q92279
Byereceiving this purchase order you agree to take appropriate measures to
secure the information and ensure the confidentiality of the patient information
is; maintained. ORIGINAL PO AND INVOICE MUST BE SUBMITTED TO THE VAMC BELOW
-7------------------------------------------------------------------------------
Department of Veterans Affairs I Prosthetic Authorization for Items or Services
------------------------ ----------- -------------------------------
1! Name and Address of V ndor RECEIVED Name and Address of VA Facility
BESA CONSTRUCTION WEST PAIM BEACH VAMC 548 (548/121)
6344 SHINNERCOCK LANE NOV 16 2M805 N. MILITARY TRAIL (548/121)
LAKE WORTH, FLORIDA 33463 WEST PAIM BEACH, FL 33410
561-847-3218 �rT�iltt�1 422 8232
ST. LuMe Cauri@m: f�mn
3 Veterans Name (Last, First, MI)
MCELANEY,CHARLES H
-=--------------------------------
5. Veterans Address
288 OLD KEYWEST PLACE
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9. Authority for Issuance CFR 17.115
CHARGE MEDICAL APPROPRIATION
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11. FOB Point 12. Discount 13. Delivery Time
DEST % 0 30 Days
FORT PIERCE, FLORIDA 34982
1 772-801-5995
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110. Statistical Data
NSC/OP
4. Date of Authorization
OCT 22, 2018
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6. Date Required
NOV 21, 2018
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14. Delivery To: VETERAN
Attention:
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15. DESCRIPTION OF ITEMS OR SERVICES AUTHORIZED
=-------------------------------------------------------------------------------
ITEM NUMBER DESCRIPTION QUANTITY UNIT UNIT AMOUNT
ORDERED PRICE
7-------------------------------------------------------------------------------
***SEE ATTACHED CONTINUATION SHEET FOR ITEM DESCRIPTION(S)***
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16. Contract Number: Subtotal: $8,999.00
�CCT.#: Discount: $ 0.00 Shipping: 0.00 Total: $8,999.00
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17. Signature of 18. Date 19. Signature and Title of 20. Date
Requesting Official Contracting/Accountable Officer
EPSTEIN,GAYLE S Brian Corey
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Order and Receipt Action
----------------------------------------------------------=---------------------
'21. Order Number 22. Exp Date 23. Date Item Received 24. Date Delivered
4716400001868552
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125. The articles or services listed herein -have been received, or rendered
ordered in the quantity and quality specified originally or'as shown by
authenticated changes, except as noted.
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Acct. Symbol 548-Q92279
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Signature of Veteran or VA Official
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ADP FORM 10-2421PC APR 1991
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