ILLINOIS INSTITUTE OF TECHNOLOGY

PARTIAL SHIPMENT PAYMENT FORM

To be used for partial payments only.  For payment of goods/services actually received in conformity with order.

Complete form and attach any support documentation and send to Accounts Payable MB201.

VENDOR__________________________              P.O. No. ___________________

                                                                                    Req. No. ___________________

                                                                                    Dept.      ___________________

                                                                                    FRS Acct No. _______________

I hereby certify that the goods or services listed above have been received in conformity with the ordering terms and payment should be made.

________________________________                    _____________________________

Signed                                                                          Date received

_________________________________                  _____________       _____________

Printed name                                                                Extension                    email