Title Page

  • Tech Name

  • Tech Number

  • Truck Number

  • Order Location

  • Ship to Location

Tool Order

Label Info

  • Tech Name

  • Tech Number

  • Van Number

Tool Information

  • * Items submitted as lost or broken will be payroll deducted.

  • * Items submitted as not issued will require FSM or Fleet Manager approval.

  • * Items submitted as worn require the explanation below, a photo of worn item, and FSM approval.

Single Items

  • Part# & Item Description

  • Cause

  • Explanation for Worn

  • Add media

  • Do you require additional Tools?

  • Part# & Item Description

  • Cause

  • Explanation for Worn

  • Add media

  • Do you require additional Tools

  • Part# & Item Description

  • Cause

  • Explanation for Worn

  • Add media

  • Do you require additional Tools

  • Part# & Item Description

  • Cause

  • Explanation for Worn

  • Add media

Multiple Items

  • Do you require additional tools

  • Part# & Item Description

  • Quantity

  • Cause

  • Explanation for Worn

  • Add media

  • Do you require additional tools

  • Part# & Item Description

  • Quantity

  • Cause

  • Explanation for Worn

  • Add media

  • Do you require additional tools

  • Part# & Item Description

  • Quantity

  • Cause

  • Explanation for Worn

  • Add media

  • Do you require additional tools

  • Part# & Item Description

  • Quantity

  • Cause

  • Explanation for Worn

  • Add media

Charges, Cost of Items, plus Tax

  • Total Cost of items being charged: Sub Total

  • Tax

  • Total to be Charged

  • *The item(s) that you are being charged for have been identified above, the total being listed above.

  • The amount owed will be deducted from your paycheck(s) per the following schedule

  • 1st Amount to be charged

  • 1st Pay Period Ending Date

  • 2nd Amount to be charged

  • 2nd Pay Period Ending Date

  • 3rd Amount to be charged

  • 3rd Pay Period Ending Date

  • Deductions taken out over multiple pay periods need FSM/ROM approval

Authorization

  • I hereby acknowledge and agree that I have filled out the above form to the best of my ability, and agree to the appropriate charges.

DRS Purchasing

  • Date:

  • Fax Date:

  • Defective Item Returned:

  • HD PO#:

  • DOW SO#:

The templates available in our Public Library have been created by our customers and employees to help get you started using SafetyCulture's solutions. The templates are intended to be used as hypothetical examples only and should not be used as a substitute for professional advice. You should seek your own professional advice to determine if the use of a template is permissible in your workplace or jurisdiction. You should independently determine whether the template is suitable for your circumstances.