Std 65 Form PDF Details

In the intricate landscape of procurement and bureaucratic navigation within the state of California, the Standard Form 65 (STD. 65), revised in July 2003, is a crucial document that facilitates the purchasing process between the State's General Services Procurement Division and its suppliers. This document not only streamlines procurement activities but also ensures that the legal and administrative frameworks governing state purchases are adhered to meticulously. It delineates detailed requirements ranging from the identification of the supplier and agency involved, down to the specifics of the purchase order including item descriptions, quantities, unit prices, and the total amount. By mandating the inclusion of contract registration numbers, agency order numbers, and detailed supplier information on both invoices and packing slips, the form underscores the importance of transparency and accountability in governmental transactions. Payment terms, certification numbers for small or microbusinesses and Disabled Veteran Business Enterprises (DVBEs), as well as the required delivery date and shipping instructions, are explicitly specified to facilitate a smooth transaction process. Furthermore, the form references the leverage of procurement agreements (LPA) and includes provisions for competitive and non-competitively bid exemptions, highlighting the State's commitment to fair and efficient procurement practices. With sections dedicated to certified correct signatures, this form not only serves as a purchase order but also as a compliance and regulatory tool, ensuring that every transaction not only meets the State's procurement needs but also adheres to legal and policy standards.

QuestionAnswer
Form NameStd 65 Form
Form Length9 pages
Fillable?No
Fillable fields0
Avg. time to fill out2 min 15 sec
Other namesE-MAIL, std 65, std 65 purchase order, CALIFORNIA

Form Preview Example

STATE OF CALIFORNIA - GENERAL SERVICES PROCUREMENT DIVISION

PURCHASING AUTHORITY PURCHASE ORDER

STD. 65 (REV. 7/2003)

CONTRACT REGISTRATION NUMBER

SUPPLIER: The numbers identified above MUST be shown on Invoice & Packing Slip.

AGENCY ORDER NUMBER

DATE

AMENDMENT NO.

PAGE OF PAGE

S H I P

T O

B

I

L L

T O

AGENCY BILLING CODE

PURCHASING AUTHORITY NUMBER

LEVERAGED PROCUREMENT AGREEMENT NO.

TO

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

INFORMATION TECHNOLOGY PROJECT IDENTIFICATION NUMBER

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SUPPLIER

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

AGENCY OR BUYER

AGENCY TRACKING/REQUISITION NUMBER (Optional)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ADDRESS

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

INFORMATION

 

 

 

 

 

 

(Type or

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

AGENCY NAME

 

CONTACT NAME

 

 

Print

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Legibly)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CONTACT E-MAIL ADDRESS

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CONTACT PHONE NUMBER

 

CONTACT FAX NUMBER

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SUPPLIER CONTACT NAME

 

 

 

 

 

 

 

SUPPLIER PHONE NUMBER

 

SUPPLIER FAX NUMBER

SUPPLIER E-MAIL ADDRESS

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PAYMENT TERMS

CERTIFICATION NUMBER

 

 

Certified

Certified

 

EXPIRATION DATE

 

Certified

EXPIRATION DATE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Small Business

Microbusiness

 

 

 

 

 

DVBE

 

 

 

REQUIRED DELIVERY DATE

 

SHIPPING

 

 

F.O.B. Destination

 

F.O.B. Destination

 

 

F.O.B.

CITY OF ORIGIN

 

 

STATE

ZIP CODE

 

 

 

 

 

 

 

 

 

 

 

FRT. PPD/ADD

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

INSTRUCTIONS

 

 

FRT. PPD

 

Freight not to exceed cost stated on P.O.

 

ORIGIN

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ITEM

 

QUANTITY

UNIT

 

COMMODITY CODE or PRODUCT CODE

RECYCLED

 

 

 

PRODUCT OR SERVICES DESCRIPTION

 

 

UNIT PRICE

 

EXTENSION TOTAL

NUMBER

 

 

or SERVICES ID NUMBER

 

PRODUCT

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

A-1

General Provisions are incorporated herein by reference to:

 

 

 

 

 

 

 

 

 

 

 

 

 

TAXABLE

 

 

Form GSPD - 401Non-IT Commodities (revision date

 

 

 

) OR

Form GSPD - 401IT (revision date

 

 

)

 

 

 

 

 

 

 

SUBTOTAL

TERMS

ATTACHED OR

Published at website: www.dgs.ca.gov/pd

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

This order is issued under a Department of General Services (DGS) Leveraged Procurement Agreement (LPA). Terms and Conditions set forth in

 

 

 

 

AND A-2

TAX RATE

 

SALES

that agreement (LPA number referenced in the block titled Leveraged Procurement Agreement No.) are incorporated herein by reference as if set

 

 

 

CONDITIONS

 

 

 

TAX

forth in full text.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

B

Agency Special Provisions are attached and titled

 

 

 

 

 

 

 

.

 

* NOTE: If there are variable

* INSTALLATION

 

 

 

 

 

 

 

 

 

 

 

C

Any other attachments, such as specifications, Statement of Work, or Information Technology Model

charges for Installation,

 

 

 

 

 

*

SHIPPING/

 

Language Modules, are identified in the product or services description area or on continuation pages.

 

 

Shipping or Freight, or Other

PROCUREMENT METHOD

 

 

 

 

 

 

 

 

 

 

 

FREIGHT

 

 

 

 

 

 

 

 

 

 

Non-Taxable Services, detail

 

 

 

 

COMPETITIVE: Solicitation Number (if applicable)

 

 

 

 

 

 

 

 

* OTHER

 

 

 

 

 

 

 

 

 

 

 

 

 

per line item and enter total

 

 

LEVERAGED

DVBE / SMALL BUSINESS [GC 14838.5(a)]

NON-COMPETITIVELY BID

EXEMPT

here.

 

 

 

 

NON-TAXABLE

PROGRAM / CATEGORY (Code and Title)

FUND TITLE

 

 

 

VERIFIED NO STATE SURPLUS

PAID BY CAL-CARD

 

 

 

 

 

 

 

 

 

 

 

 

AVAILABLE

YES

NO

YES

NO

GRAND TOTAL

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ITEM

CHAPTER

STATUTE

FISCAL YEAR OBJECT OF EXPENDITURE (CODE AND TITLE)

O.E.

EQ.

CERTIFICATION AND APPROVAL OF EXECUTIVE OFFICER

I HEREBY CERTIFY, on personal knowledge, that this order for purchasing the items specified above is issued in accordance with the procedure prescribed by law governing the purchase of such items for the State of California; and that all such legal requirements have been fully complied with.

AUTHORIZING NAME (Print or Type)

TITLE

 

 

AUTHORIZING SIGNATURE

Ｃ

UNENCUMBERED REMAINDER AFTER POSTING THIS ORDER TO ALLOTMENT EXPENDITURE LEDGER

ADJUSTMENT

INCREASING ENCUMBRANCES

ADJUSTMENT

DECREASING ENCUMBRANCES

CERTIFIED CORRECT (SIGNATURE)

Ｃ

DISTRIBUTION:

Copy 1 - Supplier; Copy 2 - DGS Procurement;

Copy 3 - Packing Slip;

Copies 4–6 - Agency Procurement File

STATE OF CALIFORNIA - GENERAL SERVICES PROCUREMENT DIVISION

PURCHASING AUTHORITY PURCHASE ORDER

STD. 65 (REV. 7/2003)

SUPPLIER INSTRUCTIONS

1.INVOICES: Unless otherwise specified, original invoices shall be sent to the "Bill To" address on the face of this document. Invoices shall be submitted in triplicate and shall include:

Contract registration number (if applicable),

Agency order number,

Item number,

Services or Product ID number,

Unit price,

Extended item price, and

Invoice total amount.

State sales tax, installation cost, shipping/freight costs, and/or other non-taxable costs shall be itemized separately and added to each invoice as applicable.

2.REQUIRED PAYMENT DATE: Payment will be made in accordance with the provisions of the California Prompt Payment Act, Government Code Section 927 et seq. Unless expressly exempted by statute, the Act requires state agencies to pay properly submitted, undisputed invoices not more than 45 days after (a) the date of acceptance of goods or performance of services; or (b) receipt of an undisputed invoice — whichever is later.

3.SHIPPING INSTRUCTIONS: When the Purchase Order or contract allows prepaid/add transportation charges, submit original receipted expense bills if freight charges are over $50.00. All shipments shall be F.O.B. Destination Freight Prepaid unless otherwise specified. All orders MUST include a copy of the packing slip inside the carton AND a copy securely attached to the OUTSIDE of the shipping carton.

STATE OF CALIFORNIA - GENERAL SERVICES PROCUREMENT DIVISION

PURCHASING AUTHORITY PURCHASE ORDER

STD. 65 (REV. 7/2003)

CONTRACT REGISTRATION NUMBER

SUPPLIER: The numbers identified above MUST be shown on Invoice & Packing Slip.

AGENCY ORDER NUMBER

DATE

AMENDMENT NO.

PAGE OF PAGE

S H I P

T O

B

I

L L

T O

AGENCY BILLING CODE

PURCHASING AUTHORITY NUMBER

LEVERAGED PROCUREMENT AGREEMENT NO.

TO

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

INFORMATION TECHNOLOGY PROJECT IDENTIFICATION NUMBER

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SUPPLIER

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

AGENCY OR BUYER

AGENCY TRACKING/REQUISITION NUMBER (Optional)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ADDRESS

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

INFORMATION

 

 

 

 

 

 

(Type or

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

AGENCY NAME

 

CONTACT NAME

 

 

Print

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Legibly)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CONTACT E-MAIL ADDRESS

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CONTACT PHONE NUMBER

 

CONTACT FAX NUMBER

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SUPPLIER CONTACT NAME

 

 

 

 

 

 

 

SUPPLIER PHONE NUMBER

 

SUPPLIER FAX NUMBER

SUPPLIER E-MAIL ADDRESS

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PAYMENT TERMS

CERTIFICATION NUMBER

 

 

Certified

Certified

 

EXPIRATION DATE

 

Certified

EXPIRATION DATE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Small Business

Microbusiness

 

 

 

 

 

DVBE

 

 

 

REQUIRED DELIVERY DATE

 

SHIPPING

 

 

F.O.B. Destination

 

F.O.B. Destination

 

 

F.O.B.

CITY OF ORIGIN

 

 

STATE

ZIP CODE

 

 

 

 

 

 

 

 

 

 

 

FRT. PPD/ADD

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

INSTRUCTIONS

 

 

FRT. PPD

 

Freight not to exceed cost stated on P.O.

 

ORIGIN

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ITEM

 

QUANTITY

UNIT

 

COMMODITY CODE or PRODUCT CODE

RECYCLED

 

 

 

PRODUCT OR SERVICES DESCRIPTION

 

 

UNIT PRICE

 

EXTENSION TOTAL

NUMBER

 

 

or SERVICES ID NUMBER

 

PRODUCT

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

A-1

General Provisions are incorporated herein by reference to:

 

 

 

 

 

 

 

 

 

 

 

 

 

TAXABLE

 

 

Form GSPD - 401Non-IT Commodities (revision date

 

 

 

) OR

Form GSPD - 401IT (revision date

 

 

)

 

 

 

 

 

 

 

SUBTOTAL

TERMS

ATTACHED OR

Published at website: www.dgs.ca.gov/pd

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

This order is issued under a Department of General Services (DGS) Leveraged Procurement Agreement (LPA). Terms and Conditions set forth in

 

 

 

 

AND A-2

TAX RATE

 

SALES

that agreement (LPA number referenced in the block titled Leveraged Procurement Agreement No.) are incorporated herein by reference as if set

 

 

 

CONDITIONS

 

 

 

TAX

forth in full text.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

B

Agency Special Provisions are attached and titled

 

 

 

 

 

 

 

.

 

* NOTE: If there are variable

* INSTALLATION

 

 

 

 

 

 

 

 

 

 

 

C

Any other attachments, such as specifications, Statement of Work, or Information Technology Model

charges for Installation,

 

 

 

 

 

*

SHIPPING/

 

Language Modules, are identified in the product or services description area or on continuation pages.

 

 

Shipping or Freight, or Other

PROCUREMENT METHOD

 

 

 

 

 

 

 

 

 

 

 

FREIGHT

 

 

 

 

 

 

 

 

 

 

Non-Taxable Services, detail

 

 

 

 

COMPETITIVE: Solicitation Number (if applicable)

 

 

 

 

 

 

 

 

* OTHER

 

 

 

 

 

 

 

 

 

 

 

 

 

per line item and enter total

 

 

LEVERAGED

DVBE / SMALL BUSINESS [GC 14838.5(a)]

NON-COMPETITIVELY BID

EXEMPT

here.

 

 

 

 

NON-TAXABLE

PROGRAM / CATEGORY (Code and Title)

FUND TITLE

 

 

 

VERIFIED NO STATE SURPLUS

PAID BY CAL-CARD

 

 

 

 

 

 

 

 

 

 

 

 

AVAILABLE

YES

NO

YES

NO

GRAND TOTAL

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ITEM

CHAPTER

STATUTE

FISCAL YEAR OBJECT OF EXPENDITURE (CODE AND TITLE)

O.E.

EQ.

CERTIFICATION AND APPROVAL OF EXECUTIVE OFFICER

I HEREBY CERTIFY, on personal knowledge, that this order for purchasing the items specified above is issued in accordance with the procedure prescribed by law governing the purchase of such items for the State of California; and that all such legal requirements have been fully complied with.

AUTHORIZING NAME (Print or Type)

TITLE

 

 

AUTHORIZING SIGNATURE

Ｃ

UNENCUMBERED REMAINDER AFTER POSTING THIS ORDER TO ALLOTMENT EXPENDITURE LEDGER

ADJUSTMENT

INCREASING ENCUMBRANCES

ADJUSTMENT

DECREASING ENCUMBRANCES

CERTIFIED CORRECT (SIGNATURE)

Ｃ

DISTRIBUTION:

Copy 1 - Supplier; Copy 2 - DGS Procurement;

Copy 3 - Packing Slip;

Copies 4–6 - Agency Procurement File

DEPARTMENT OF GENERAL SERVICES

Procurement Division

Data Entry Unit - Second Floor

P.O. Box 989052

West Sacramento, CA 95798-9052

STATE OF CALIFORNIA - GENERAL SERVICES PROCUREMENT DIVISION

PURCHASING AUTHORITY PURCHASE ORDER

STD. 65 (REV. 7/2003)

CONTRACT REGISTRATION NUMBER

SUPPLIER: The numbers identified above MUST be shown on Invoice & Packing Slip.

AGENCY ORDER NUMBER

DATE

AMENDMENT NO.

PAGE OF PAGE

S H I P

T O

B

I

L L

T O

AGENCY BILLING CODE

PURCHASING AUTHORITY NUMBER

LEVERAGED PROCUREMENT AGREEMENT NO.

TO

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

INFORMATION TECHNOLOGY PROJECT IDENTIFICATION NUMBER

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SUPPLIER

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

AGENCY OR BUYER

AGENCY TRACKING/REQUISITION NUMBER (Optional)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ADDRESS

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

INFORMATION

 

 

 

 

 

 

(Type or

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

AGENCY NAME

 

CONTACT NAME

 

 

Print

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Legibly)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CONTACT E-MAIL ADDRESS

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CONTACT PHONE NUMBER

 

CONTACT FAX NUMBER

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SUPPLIER CONTACT NAME

 

 

 

 

 

 

 

SUPPLIER PHONE NUMBER

 

SUPPLIER FAX NUMBER

SUPPLIER E-MAIL ADDRESS

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PAYMENT TERMS

CERTIFICATION NUMBER

 

 

Certified

Certified

 

EXPIRATION DATE

 

Certified

EXPIRATION DATE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Small Business

Microbusiness

 

 

 

 

 

DVBE

 

 

 

REQUIRED DELIVERY DATE

 

SHIPPING

 

 

F.O.B. Destination

 

F.O.B. Destination

 

 

F.O.B.

CITY OF ORIGIN

 

 

STATE

ZIP CODE

 

 

 

 

 

 

 

 

 

 

 

FRT. PPD/ADD

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

INSTRUCTIONS

 

 

FRT. PPD

 

Freight not to exceed cost stated on P.O.

 

ORIGIN

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ITEM

 

QUANTITY

UNIT

 

COMMODITY CODE or PRODUCT CODE

RECYCLED

 

 

 

PRODUCT OR SERVICES DESCRIPTION

 

 

UNIT PRICE

 

EXTENSION TOTAL

NUMBER

 

 

or SERVICES ID NUMBER

 

PRODUCT

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

A-1

 

General Provisions are incorporated herein by reference to:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

TAXABLE

 

 

 

 

 

 

Form GSPD - 401Non-IT Commodities (revision date

 

 

 

) OR

Form GSPD - 401IT (revision date

 

 

)

 

 

 

 

 

 

 

 

 

 

 

SUBTOTAL

TERMS

ATTACHED OR

Published at website: www.dgs.ca.gov/pd

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

This order is issued under a Department of General Services (DGS) Leveraged Procurement Agreement (LPA). Terms and Conditions set forth in

 

 

 

 

AND

A-2

 

 

TAX RATE

 

SALES

 

that agreement (LPA number referenced in the block titled Leveraged Procurement Agreement No.) are incorporated herein by reference as if set

 

 

 

CONDITIONS

 

 

 

TAX

forth in full text.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

B

 

Agency Special Provisions are attached and titled

 

 

 

 

 

 

 

 

.

 

* NOTE: If there are variable

* INSTALLATION

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Any other attachments, such as specifications, Statement of Work, or Information Technology Model

charges for Installation,

 

 

 

 

 

 

 

C

 

 

*

SHIPPING/

 

 

 

 

Language Modules, are identified in the product or services description area or on continuation pages.

 

 

 

 

 

 

Shipping or Freight, or Other

 

 

 

 

 

 

PROCUREMENT METHOD

 

 

 

 

 

 

 

 

 

 

 

 

FREIGHT

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Non-Taxable Services, detail

 

 

 

 

 

 

 

 

COMPETITIVE: Solicitation Number (if applicable)

 

 

 

 

 

 

 

 

 

* OTHER

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

per line item and enter total

 

 

LEVERAGED

DVBE / SMALL BUSINESS [GC 14838.5(a)]

NON-COMPETITIVELY BID

EXEMPT

here.

 

 

 

 

NON-TAXABLE

PROGRAM / CATEGORY (Code and Title)

FUND TITLE

 

 

 

VERIFIED NO STATE SURPLUS

PAID BY CAL-CARD

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

AVAILABLE

YES

NO

YES

NO

GRAND TOTAL

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ITEM

CHAPTER

STATUTE

FISCAL YEAR OBJECT OF EXPENDITURE (CODE AND TITLE)

O.E.

EQ.

CERTIFICATION AND APPROVAL OF EXECUTIVE OFFICER

I HEREBY CERTIFY, on personal knowledge, that this order for purchasing the items specified above is issued in accordance with the procedure prescribed by law governing the purchase of such items for the State of California; and that all such legal requirements have been fully complied with.

AUTHORIZING NAME (Print or Type)

TITLE

 

 

AUTHORIZING SIGNATURE

Ｃ

UNENCUMBERED REMAINDER AFTER POSTING THIS ORDER TO ALLOTMENT EXPENDITURE LEDGER

ADJUSTMENT

INCREASING ENCUMBRANCES

ADJUSTMENT

DECREASING ENCUMBRANCES

CERTIFIED CORRECT (SIGNATURE)

Ｃ

DISTRIBUTION:

Copy 1 - Supplier; Copy 2 - DGS Procurement;

Copy 3 - Packing Slip;

Copies 4–6 - Agency Procurement File

STATE OF CALIFORNIA - GENERAL SERVICES PROCUREMENT DIVISION

PURCHASING AUTHORITY PURCHASE ORDER

STD. 65 (REV. 7/2003)

CONTRACT REGISTRATION NUMBER

SUPPLIER: The numbers identified above MUST be shown on Invoice & Packing Slip.

AGENCY ORDER NUMBER

DATE

AMENDMENT NO.

PAGE OF PAGE

S H I P

T O

B

I

L L

T O

AGENCY BILLING CODE

PURCHASING AUTHORITY NUMBER

LEVERAGED PROCUREMENT AGREEMENT NO.

TO

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

INFORMATION TECHNOLOGY PROJECT IDENTIFICATION NUMBER

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SUPPLIER

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

AGENCY OR BUYER

AGENCY TRACKING/REQUISITION NUMBER (Optional)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ADDRESS

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

INFORMATION

 

 

 

 

 

 

(Type or

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

AGENCY NAME

 

CONTACT NAME

 

 

Print

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Legibly)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CONTACT E-MAIL ADDRESS

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CONTACT PHONE NUMBER

 

CONTACT FAX NUMBER

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SUPPLIER CONTACT NAME

 

 

 

 

 

 

 

SUPPLIER PHONE NUMBER

 

SUPPLIER FAX NUMBER

SUPPLIER E-MAIL ADDRESS

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PAYMENT TERMS

CERTIFICATION NUMBER

 

 

Certified

Certified

 

EXPIRATION DATE

 

Certified

EXPIRATION DATE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Small Business

Microbusiness

 

 

 

 

 

DVBE

 

 

 

REQUIRED DELIVERY DATE

 

SHIPPING

 

 

F.O.B. Destination

 

F.O.B. Destination

 

 

F.O.B.

CITY OF ORIGIN

 

 

STATE

ZIP CODE

 

 

 

 

 

 

 

 

 

 

 

FRT. PPD/ADD

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

INSTRUCTIONS

 

 

FRT. PPD

 

Freight not to exceed cost stated on P.O.

 

ORIGIN

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ITEM

 

QUANTITY

UNIT

 

COMMODITY CODE or PRODUCT CODE

RECYCLED

 

 

 

PRODUCT OR SERVICES DESCRIPTION

 

 

UNIT PRICE

 

EXTENSION TOTAL

NUMBER

 

 

or SERVICES ID NUMBER

 

PRODUCT

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

A-1

General Provisions are incorporated herein by reference to:

 

 

 

 

 

 

 

 

 

 

 

 

 

TAXABLE

 

 

Form GSPD - 401Non-IT Commodities (revision date

 

 

 

) OR

Form GSPD - 401IT (revision date

 

 

)

 

 

 

 

 

 

 

SUBTOTAL

TERMS

ATTACHED OR

Published at website: www.dgs.ca.gov/pd

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

This order is issued under a Department of General Services (DGS) Leveraged Procurement Agreement (LPA). Terms and Conditions set forth in

 

 

 

 

AND A-2

TAX RATE

 

SALES

that agreement (LPA number referenced in the block titled Leveraged Procurement Agreement No.) are incorporated herein by reference as if set

 

 

 

CONDITIONS

 

 

 

TAX

forth in full text.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

B

Agency Special Provisions are attached and titled

 

 

 

 

 

 

 

.

 

* NOTE: If there are variable

* INSTALLATION

 

 

 

 

 

 

 

 

 

 

 

C

Any other attachments, such as specifications, Statement of Work, or Information Technology Model

charges for Installation,

 

 

 

 

 

*

SHIPPING/

 

Language Modules, are identified in the product or services description area or on continuation pages.

 

 

Shipping or Freight, or Other

PROCUREMENT METHOD

 

 

 

 

 

 

 

 

 

 

 

FREIGHT

 

 

 

 

 

 

 

 

 

 

Non-Taxable Services, detail

 

 

 

 

COMPETITIVE: Solicitation Number (if applicable)

 

 

 

 

 

 

 

 

* OTHER

 

 

 

 

 

 

 

 

 

 

 

 

 

per line item and enter total

 

 

LEVERAGED

DVBE / SMALL BUSINESS [GC 14838.5(a)]

NON-COMPETITIVELY BID

EXEMPT

here.

 

 

 

 

NON-TAXABLE

PROGRAM / CATEGORY (Code and Title)

FUND TITLE

 

 

 

VERIFIED NO STATE SURPLUS

PAID BY CAL-CARD

 

 

 

 

 

 

 

 

 

 

 

 

AVAILABLE

YES

NO

YES

NO

GRAND TOTAL

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ITEM

CHAPTER

STATUTE

FISCAL YEAR OBJECT OF EXPENDITURE (CODE AND TITLE)

O.E.

EQ.

CERTIFICATION AND APPROVAL OF EXECUTIVE OFFICER

I HEREBY CERTIFY, on personal knowledge, that this order for purchasing the items specified above is issued in accordance with the procedure prescribed by law governing the purchase of such items for the State of California; and that all such legal requirements have been fully complied with.

AUTHORIZING NAME (Print or Type)

TITLE

 

 

AUTHORIZING SIGNATURE

Ｃ

UNENCUMBERED REMAINDER AFTER POSTING THIS ORDER TO ALLOTMENT EXPENDITURE LEDGER

ADJUSTMENT

INCREASING ENCUMBRANCES

ADJUSTMENT

DECREASING ENCUMBRANCES

CERTIFIED CORRECT (SIGNATURE)

Ｃ

DISTRIBUTION:

Copy 1 - Supplier; Copy 2 - DGS Procurement;

Copy 3 - Packing Slip;

Copies 4–6 - Agency Procurement File

STATE OF CALIFORNIA - GENERAL SERVICES PROCUREMENT DIVISION

PURCHASING AUTHORITY PURCHASE ORDER

STD. 65 (REV. 7/2003)

CONTRACT REGISTRATION NUMBER

SUPPLIER: The numbers identified above MUST be shown on Invoice & Packing Slip.

AGENCY ORDER NUMBER

DATE

AMENDMENT NO.

PAGE OF PAGE

S H I P

T O

B

I

L L

T O

AGENCY BILLING CODE

PURCHASING AUTHORITY NUMBER

LEVERAGED PROCUREMENT AGREEMENT NO.

TO

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

INFORMATION TECHNOLOGY PROJECT IDENTIFICATION NUMBER

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SUPPLIER

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

AGENCY OR BUYER

AGENCY TRACKING/REQUISITION NUMBER (Optional)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ADDRESS

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

INFORMATION

 

 

 

 

 

 

(Type or

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

AGENCY NAME

 

CONTACT NAME

 

 

Print

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Legibly)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CONTACT E-MAIL ADDRESS

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CONTACT PHONE NUMBER

 

CONTACT FAX NUMBER

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SUPPLIER CONTACT NAME

 

 

 

 

 

 

 

SUPPLIER PHONE NUMBER

 

SUPPLIER FAX NUMBER

SUPPLIER E-MAIL ADDRESS

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PAYMENT TERMS

CERTIFICATION NUMBER

 

 

Certified

Certified

 

EXPIRATION DATE

 

Certified

EXPIRATION DATE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Small Business

Microbusiness

 

 

 

 

 

DVBE

 

 

 

REQUIRED DELIVERY DATE

 

SHIPPING

 

 

F.O.B. Destination

 

F.O.B. Destination

 

 

F.O.B.

CITY OF ORIGIN

 

 

STATE

ZIP CODE

 

 

 

 

 

 

 

 

 

 

 

FRT. PPD/ADD

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

INSTRUCTIONS

 

 

FRT. PPD

 

Freight not to exceed cost stated on P.O.

 

ORIGIN

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ITEM

 

QUANTITY

UNIT

 

COMMODITY CODE or PRODUCT CODE

RECYCLED

 

 

 

PRODUCT OR SERVICES DESCRIPTION

 

 

UNIT PRICE

 

EXTENSION TOTAL

NUMBER

 

 

or SERVICES ID NUMBER

 

PRODUCT

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

A-1

General Provisions are incorporated herein by reference to:

 

 

 

 

 

 

 

 

 

 

 

 

 

TAXABLE

 

 

Form GSPD - 401Non-IT Commodities (revision date

 

 

 

) OR

Form GSPD - 401IT (revision date

 

 

)

 

 

 

 

 

 

 

SUBTOTAL

TERMS

ATTACHED OR

Published at website: www.dgs.ca.gov/pd

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

This order is issued under a Department of General Services (DGS) Leveraged Procurement Agreement (LPA). Terms and Conditions set forth in

 

 

 

 

AND A-2

TAX RATE

 

SALES

that agreement (LPA number referenced in the block titled Leveraged Procurement Agreement No.) are incorporated herein by reference as if set

 

 

 

CONDITIONS

 

 

 

TAX

forth in full text.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

B

Agency Special Provisions are attached and titled

 

 

 

 

 

 

 

.

 

* NOTE: If there are variable

* INSTALLATION

 

 

 

 

 

 

 

 

 

 

 

C

Any other attachments, such as specifications, Statement of Work, or Information Technology Model

charges for Installation,

 

 

 

 

 

*

SHIPPING/

 

Language Modules, are identified in the product or services description area or on continuation pages.

 

 

Shipping or Freight, or Other

PROCUREMENT METHOD

 

 

 

 

 

 

 

 

 

 

 

FREIGHT

 

 

 

 

 

 

 

 

 

 

Non-Taxable Services, detail

 

 

 

 

COMPETITIVE: Solicitation Number (if applicable)

 

 

 

 

 

 

 

 

* OTHER

 

 

 

 

 

 

 

 

 

 

 

 

 

per line item and enter total

 

 

LEVERAGED

DVBE / SMALL BUSINESS [GC 14838.5(a)]

NON-COMPETITIVELY BID

EXEMPT

here.

 

 

 

 

NON-TAXABLE

PROGRAM / CATEGORY (Code and Title)

FUND TITLE

 

 

 

VERIFIED NO STATE SURPLUS

PAID BY CAL-CARD

 

 

 

 

 

 

 

 

 

 

 

 

AVAILABLE

YES

NO

YES

NO

GRAND TOTAL

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ITEM

CHAPTER

STATUTE

FISCAL YEAR OBJECT OF EXPENDITURE (CODE AND TITLE)

O.E.

EQ.

CERTIFICATION AND APPROVAL OF EXECUTIVE OFFICER

I HEREBY CERTIFY, on personal knowledge, that this order for purchasing the items specified above is issued in accordance with the procedure prescribed by law governing the purchase of such items for the State of California; and that all such legal requirements have been fully complied with.

AUTHORIZING NAME (Print or Type)

TITLE

 

 

AUTHORIZING SIGNATURE

Ｃ

UNENCUMBERED REMAINDER AFTER POSTING THIS ORDER TO ALLOTMENT EXPENDITURE LEDGER

ADJUSTMENT

INCREASING ENCUMBRANCES

ADJUSTMENT

DECREASING ENCUMBRANCES

CERTIFIED CORRECT (SIGNATURE)

Ｃ

DISTRIBUTION:

Copy 1 - Supplier; Copy 2 - DGS Procurement;

Copy 3 - Packing Slip;

Copies 4–6 - Agency Procurement File

STATE OF CALIFORNIA - GENERAL SERVICES PROCUREMENT DIVISION

PURCHASING AUTHORITY PURCHASE ORDER

STD. 65 (REV. 7/2003)

CONTRACT REGISTRATION NUMBER

SUPPLIER: The numbers identified above MUST be shown on Invoice & Packing Slip.

AGENCY ORDER NUMBER

DATE

AMENDMENT NO.

PAGE OF PAGE

S H I P

T O

B

I

L L

T O

AGENCY BILLING CODE

PURCHASING AUTHORITY NUMBER

LEVERAGED PROCUREMENT AGREEMENT NO.

TO

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

INFORMATION TECHNOLOGY PROJECT IDENTIFICATION NUMBER

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SUPPLIER

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

AGENCY OR BUYER

AGENCY TRACKING/REQUISITION NUMBER (Optional)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ADDRESS

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

INFORMATION

 

 

 

 

 

 

(Type or

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

AGENCY NAME

 

CONTACT NAME

 

 

Print

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Legibly)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CONTACT E-MAIL ADDRESS

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CONTACT PHONE NUMBER

 

CONTACT FAX NUMBER

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SUPPLIER CONTACT NAME

 

 

 

 

 

 

 

SUPPLIER PHONE NUMBER

 

SUPPLIER FAX NUMBER

SUPPLIER E-MAIL ADDRESS

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PAYMENT TERMS

CERTIFICATION NUMBER

 

 

Certified

Certified

 

EXPIRATION DATE

 

Certified

EXPIRATION DATE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Small Business

Microbusiness

 

 

 

 

 

DVBE

 

 

 

REQUIRED DELIVERY DATE

 

SHIPPING

 

 

F.O.B. Destination

 

F.O.B. Destination

 

 

F.O.B.

CITY OF ORIGIN

 

 

STATE

ZIP CODE

 

 

 

 

 

 

 

 

 

 

 

FRT. PPD/ADD

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

INSTRUCTIONS

 

 

FRT. PPD

 

Freight not to exceed cost stated on P.O.

 

ORIGIN

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ITEM

 

QUANTITY

UNIT

 

COMMODITY CODE or PRODUCT CODE

RECYCLED

 

 

 

PRODUCT OR SERVICES DESCRIPTION

 

 

UNIT PRICE

 

EXTENSION TOTAL

NUMBER

 

 

or SERVICES ID NUMBER

 

PRODUCT

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

A-1

General Provisions are incorporated herein by reference to:

 

 

 

 

 

 

 

 

 

 

 

 

 

TAXABLE

 

 

Form GSPD - 401Non-IT Commodities (revision date

 

 

 

) OR

Form GSPD - 401IT (revision date

 

 

)

 

 

 

 

 

 

 

SUBTOTAL

TERMS

ATTACHED OR

Published at website: www.dgs.ca.gov/pd

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

This order is issued under a Department of General Services (DGS) Leveraged Procurement Agreement (LPA). Terms and Conditions set forth in

 

 

 

 

AND A-2

TAX RATE

 

SALES

that agreement (LPA number referenced in the block titled Leveraged Procurement Agreement No.) are incorporated herein by reference as if set

 

 

 

CONDITIONS

 

 

 

TAX

forth in full text.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

B

Agency Special Provisions are attached and titled

 

 

 

 

 

 

 

.

 

* NOTE: If there are variable

* INSTALLATION

 

 

 

 

 

 

 

 

 

 

 

C

Any other attachments, such as specifications, Statement of Work, or Information Technology Model

charges for Installation,

 

 

 

 

 

*

SHIPPING/

 

Language Modules, are identified in the product or services description area or on continuation pages.

 

 

Shipping or Freight, or Other

PROCUREMENT METHOD

 

 

 

 

 

 

 

 

 

 

 

FREIGHT

 

 

 

 

 

 

 

 

 

 

Non-Taxable Services, detail

 

 

 

 

COMPETITIVE: Solicitation Number (if applicable)

 

 

 

 

 

 

 

 

* OTHER

 

 

 

 

 

 

 

 

 

 

 

 

 

per line item and enter total

 

 

LEVERAGED

DVBE / SMALL BUSINESS [GC 14838.5(a)]

NON-COMPETITIVELY BID

EXEMPT

here.

 

 

 

 

NON-TAXABLE

PROGRAM / CATEGORY (Code and Title)

FUND TITLE

 

 

 

VERIFIED NO STATE SURPLUS

PAID BY CAL-CARD

 

 

 

 

 

 

 

 

 

 

 

 

AVAILABLE

YES

NO

YES

NO

GRAND TOTAL

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ITEM

CHAPTER

STATUTE

FISCAL YEAR OBJECT OF EXPENDITURE (CODE AND TITLE)

O.E.

EQ.

CERTIFICATION AND APPROVAL OF EXECUTIVE OFFICER

I HEREBY CERTIFY, on personal knowledge, that this order for purchasing the items specified above is issued in accordance with the procedure prescribed by law governing the purchase of such items for the State of California; and that all such legal requirements have been fully complied with.

AUTHORIZING NAME (Print or Type)

TITLE

 

 

AUTHORIZING SIGNATURE

Ｃ

UNENCUMBERED REMAINDER AFTER POSTING THIS ORDER TO ALLOTMENT EXPENDITURE LEDGER

ADJUSTMENT

INCREASING ENCUMBRANCES

ADJUSTMENT

DECREASING ENCUMBRANCES

CERTIFIED CORRECT (SIGNATURE)

Ｃ

DISTRIBUTION:

Copy 1 - Supplier; Copy 2 - DGS Procurement;

Copy 3 - Packing Slip;

Copies 4–6 - Agency Procurement File

STATE OF CALIFORNIA − GENERAL SERVICES PROCUREMENT DIVISION

PURCHASING AUTHORITY PURCHASE ORDER

STD. 65 (REV. 7/2003) (REVERSE)

INSTRUCTIONS FOR COMPLETING THE PURCHASING AUTHORITY PURCHASE ORDER

1.CONTRACT REGISTRATION NUMBER: All purchases of goods or services over $5,000.00 require a Contract Registration Number. This number must be placed on all supplier invoices in order to process payments.

2.AGENCY ORDER NUMBER: Enter the appropriate agency order number as prescribed by your agency. Agency order number must be unique from transaction to transaction and from year to year (e.g., 03-001, 03-002, etc.; "03" represents the fiscal year of issue). Agency order number must not exceed fifteen (15) characters in length. This number must also be placed on all supplier invoices and packing slips in order to process payments and receive products and services.

3.AMENDMENT NO.: Enter the appropriate amendment number (e.g., 1, 2, 3, etc.) as amendments occur. Amendments are necessary when ANY change in the order occurs. This includes change in descriptions, costs, quantities, etc.

4.DATE: Enter the date the order is prepared. The month and day should be indicated with two (2) digits and the year with four (4) digits (i.e., July 1, 2003 is 07/01/2003).

5.PAGE OF PAGE: Enter page number and total number of pages for each order. This should be shown with two (2) digits (e.g., enter 01/01 for page 1 of 1). If needed, use STD. 65A (Purchasing Authority Purchase Order Continuation).

6.AGENCY BILLING CODE: Enter Agency Billing Code. A five-digit or six-digit code issued by the Department of General Services (DGS) for billing purposes.

7.PURCHASING AUTHORITY NUMBER: Enter your department's purchasing authority number as assigned by DGS. This number MUST be entered for all IT transactions $0.00 and over and Non-IT goods transactions over $100.00.

8.LEVERAGED PROCUREMENT AGREEMENT (LPA) NO.: Enter the appropriate leveraged procurement agreement number (e.g., California Multiple Award Schedule (CMAS) Contract, Master Agreement, State Price Schedule, etc.).

9.INFORMATION TECHNOLOGY PROJECT IDENTIFICATION NUMBER: For procurement of information technology goods or services, enter one of the following identification numbers: Project Number, Department Assigned Internal Project Number, Department Assigned Work Group Computing Justification Form Number (WCJF).

10.AGENCY TRACKING/REQUISITION NUMBER: Enter any agency internal purchase request(s) number to assist with internal tracking of this purchasing authority purchase order.

11.PAYMENT TERMS: Cash discount offered by the supplier if payment is postmarked within a specific number of days (discount period) or a discount offered per the contract terms (e.g., 2% Net 30, Net 30).

12.CERTIFIED SMALL BUSINESS, MICROBUSINESS AND CERTIFIED DISABLED VETERAN BUSINESS ENTERPRISE: Check the appropriate box(es) if the supplier is a California certified Small Business/Microbusiness or DVBE as certified by the Office of Small Business and DVBE Certification (OSDC). Verify expiration date and enter date in the space provided.

13. REQUIRED DELIVERY DATE: Enter the required delivery date for all items, or indicate the time period after receipt of order (ARO) for delivery. If multiple delivery dates are required enter "see item" or "as specified" and include specific dates in the item description or use an attachment to define. Date(s) should be the same as established in any applicable solicitation, or leveraged procurement agreement, unless otherwise agreed upon, in writing, signed by all parties and approved as required.

14.SHIPPING INSTRUCTIONS: Enter shipping information such as Free on Board (F.O.B.); Destination (DEST); Freight (FRT); Prepaid (PPD); F.O.B. Destination, Freight Prepaid and Add (PPD/ADD); F.O.B. Origin, Freight Collect (COLL). If assistance is needed, contact DGS Procurement Division (PD) Transportation Management (TM) for contracted carrier information.

15.ITEM NUMBER: Enter item number(s) in sequential order.

16.QUANTITY: Enter appropriate numeric quantity.

17.UNIT: Enter the order unit of measure. Examples: ea - each; pk - package; bx - box; st - set.

18.COMMODITY CODE or PRODUCT CODE or SERVICES ID NUMBER: Include the applicable commodity code, product code, or services identification number, i.e., PIN number, part number, catalog number, SKU number, etc. in this column.

19.RECYCLED PRODUCT: Check the "Recycle" column when the product being purchased is a reportable product. Reportable products are any products that fall into one of the following categories: antifreeze, compost/co-compost, glass, lubricating oils, paint, plastic products, paper products, printing and writing papers, solvents, steel, tires, and/or tire-derived products.

20.PRODUCT OR SERVICES DESCRIPTION: For leveraged procurement agreements established by DGS, enter the description exactly as worded in the referenced agreement. For other acquisitions, use wording to accurately describe the product(s) or services ordered, including brand, model, version, etc. Descriptions should include all features, components, supplies, etc., or reference to attachments with detailed descriptions.

21.UNIT PRICE: The unit price or service rate (e.g., hourly, weekly or monthly rate) must be entered for each line item. For leveraged procurement agreements established by DGS, enter the unit price stated in the referenced LPA. For other acquisitions, enter the unit price contained in the supplier's bid, proposal, or as negotiated.

22.EXTENSION TOTAL: Multiply the product quantity times the unit price and enter the result.

23.TERMS AND CONDITIONS:

A-1: For competitive or non-competitive bids check the applicable box(es) to indicate the appropriate General Provisions are being used and are incorporated into the order and insert the applicable revision date. Use the version contained in the solicitation and resulting bid with the supplier. A hard copy must be attached, OR reference made to the Procurement Division web page at www.dgs.ca.gov/pd.

OR

A-2: Check the second box if the order is being placed under a leveraged procurement agreement, as those agreements contain all the required terms and conditions.

B:Check the third box if any Agency Special Provisions are applicable. Agency Special Provisions may be used to supplement the general provisions and/or tailor the purchase order as agreed upon by all parties. To incorporate Agency Special Provisions, insert, on the blank line, the name (or other identification) of the form or document used.

C:Check this box as applicable when attaching specifications, Statement of Work or using IT model language modules.

24.PROCUREMENT METHOD: Check the appropriate box as applicable to the transaction being issued. For more information on requirements for each method, refer to the purchasing authority manual available on the DGS Procurement Division web page. "Exempt" should be checked for those transactions exempted by law (e.g., sheltered workshop or Community Based Rehabilitation Programs [CBRP] purchases).

25.VERIFIED NO STATE SURPLUS AVAILABLE: Check the appropriate box in support of the agency's effort to use existing State inventory as appropriate prior to an acquisition.

26.PAID BY CAL-CARD: Check the appropriate box.

DISTRIBUTION:

The Purchasing Authority Purchase Order MUST be distributed as follows:

COPY 1: SEND TO SUPPLIER

COPY 2: DEPARTMENT OF GENERAL SERVICES

Procurement Division

Data Entry Unit - Second Floor

P.O. Box 989052, West Sacramento, CA 95798-9052

DGS Procurement Division's mailing address is pre-printed on the back of Copy 2 for mailing purposes (fits #10 window envelopes).

COPY 3: PACKING SLIP (Send to supplier)

COPIES 4 – 6: AGENCY PROCUREMENT FILE

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In an effort to fill out this document, be sure you provide the right details in every single blank field:

1. The Microbusiness necessitates certain information to be entered. Make certain the next blanks are filled out:

std 65 writing process explained (part 1)

2. When the first part is filled out, proceed to enter the applicable details in all these - ITEM, NUMBER, QUANTITY, UNIT, COMMODITY CODE or PRODUCT CODE, or SERVICES ID NUMBER, RECYCLED PRODUCT, PRODUCT OR SERVICES DESCRIPTION, UNIT PRICE, EXTENSION TOTAL, General Provisions are, Form GSPD NonIT Commodities, Form GSPD IT revision date, TERMS, and AND.

Filling out segment 2 in std 65

People often get some points wrong while completing COMMODITY CODE or PRODUCT CODE in this area. Be sure to revise everything you type in right here.

3. This next section is about ITEM, CHAPTER, STATUTE, FISCAL YEAR, OBJECT OF EXPENDITURE CODE AND, CERTIFICATION, AND, APPROVAL F EXECUTIVE FFICER, I HEREBY CERTIFY on personal, AUTHORIZING NAME Print or Type, TITLE, AUTHORIZING SIGNATURE, UNENCUMBERED REMAINDER AFTER, ADJUSTMENT INCREASING ENCUMBRANCES, and ADJUSTMENT DECREASING ENCUMBRANCES - fill out all of these blanks.

Learn how to fill in std 65 part 3

4. To go forward, this stage requires completing a couple of blanks. These include STATE OF CALIFORNIA GENERAL, CONTRACT REGISTRATION NUMBER, AGENCY ORDER NUMBER, AMENDMENT NO, SUPPLIER The numbers identified, DATE, PAGE, PAGE, S H I P, T O, TO SUPPLIER ADDRESS, Type or Print Legibly, B I L L, T O, and AGENCY BILLING CODE, which you'll find crucial to carrying on with this particular process.

Part # 4 in submitting std 65

5. This final step to conclude this PDF form is crucial. You need to fill out the necessary fields, for example ITEM, NUMBER, QUANTITY, UNIT, COMMODITY CODE or PRODUCT CODE, or SERVICES ID NUMBER, RECYCLED PRODUCT, PRODUCT OR SERVICES DESCRIPTION, UNIT PRICE, EXTENSION TOTAL, General Provisions are, Form GSPD NonIT Commodities, Form GSPD IT revision date, TERMS, and AND, before using the pdf. Neglecting to accomplish that might contribute to an unfinished and possibly invalid document!

Stage number 5 in submitting std 65

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