Fixed Asset Acquisition Form

1. REQUEST

(Instructions on back)

Date
Initiated:

Item Requested:

Detailed Description:
Preferred Vendor:

Date Needed:

Requested By:

Program:

Program Number:

Amount
Requested:

Is Funding Source Approval Required: YES

NO

If yes, attach proof of approval.

2. PROGRAM MANAGER
Capital

Signature:
Is MHS Owner? YES

OR Expense

ACCOUNTING CODE:

NO

If no, who is owner?

CONTRACT NUMBER:

3. REVIEW AND APPROVAL

VICE PRESIDENT
Amount Authorized:
Senior VP or
Executive
Approval:(If =>$2,000)

VP Signature:

EA Signature:

______________________________

4. RECEIPT
Date
Model #:
Received:
Attach invoice or packing slip? Yes __ No__

Serial #:
Received By:

NOTE: After item is received, this form must be sent to Accounting for payment authorization.
5. RECORD (FAC. DEPT.)
Assigned Inventory Tag #:

Entered in Facilities Database:

DVD/CD
Players
TVs
Copiers

By:

Date:

FIXED ASSET PURCHASES REQUIRING THIS FORM

Only use this form when purchasing the following items:

All telephones (not

cell chargers)
Video Game Consoles
Desks / furniture items
costing over $50

CD Players

Cameras of any type

Refrigerators
Office Equipment
costing over $50

Microwave Ovens
Any single item costing over
$500 (except software)

Please use the IT Hardware Request Form for ordering all computer equipment: