Material Request

Field Tech parts order request :
Date of Request :

Requested By (Name & Phone #) :

Date required on-site :

Urgency (Overnight First AM, Overnight, Ground) :

Delivery Address :

Account ID Number (13xxx):

Account Name:

Unit Number:

Charge to construction, maintenance, open order, or CB-Owner

Part Description / Part Number (Order 1) :

Proposed Vendor (Order 1) :

Quantity of Parts (Order 1):

Cost Per Part (Order 1)-Office Only:

Total Cost (Order 1)-Office Only:

Part Description / Part Number (Order 2):

Proposed Vendor (Order 2):

Quantity of Parts (Order 2):

Cost Per Part (Order 2)-Office Only:

Total Cost (Order 2)-Office Only:

Part Description / Part Number (Order 3):

Proposed Vendor (Order 3):

Quantity of Parts (Order 3):

Cost Per Part (Order 3)-Office Only:

Total Cost (Order 3)-Office Only:

Part Description / Part Number (Order 4):

Proposed Vendor (Order 4):

Quantity of Parts (Order 4):

Cost Per Part (Order 4)-Office Only;

Total Cost (Order 4)-Office Only:

Part Description / Part Number (Order 5):

Proposed Vendor (Order 5):

Quantity of Parts (Order 5):

Cost Per Part (Order 5)-Office Only:

Total Cost (Order 5)-Office Only:

NOTES: Please provide the reason for parts (equipment failure, wiring for machine, misuse, etc.) OR any other pertinent info:

PICTURES: Please take an applicable pictures of parts, part numbers, etc:
Please note that this checklist is a hypothetical example and provides basic information only. It is not intended to take the place of, among other things, workplace, health and safety advice; medical advice, diagnosis, or treatment; or other applicable laws. You should also seek your own professional advice to determine if the use of such checklist is permissible in your workplace or jurisdiction.