OFFICE MAX / RUDOLPH'S / STORES PURCHASE AUTHORIZATION FORM
(Please type form and sign in ink)
FAX 301.314.9255
DEPT. NAME:___________________________________________________________________________________

MAILING ADDRESS (other than College Park Campus)_______________________________________________

_____________________________________________________________________________________________

Chair / Dir. Name :____________________________________UID: __________________________

Rm.: ________ Bldg: ___________Campus: ___________ E-Mail Address: ___________________________

I delegate to the following staff the authority to purchase from General Stores using the FRS Account Numbers and
delivery locations listed below :

Chair / Dir. Signature ________________________________________ Date ________________________

---

FRS Account Number : __________________________________________Authorization Code :_____________

Authorized Purchasers :

FAX #:___________________________

Name: _________________________________ UID : ______________________ Phone # : ___________________

Mailing Address : Rm# ___________ Bldg # :____________ E-Mail : ___________________________________

Name: _________________________________ UID : ______________________ Phone # : ___________________

Mailing Address : Rm# ___________ Bldg # :____________ E-Mail : ___________________________________

Delivery Locations :
Primary - Rm # _______________ Bldg. # ___________ Bldg Name : ___________________________

Alternate # 1 - Rm # ___________ Bldg. # ___________ Bldg Name : ___________________________

Alternate # 2 - Rm # ___________ Bldg. # ___________ Bldg Name : ___________________________

---