WS Form 17 Pocatello Supply Depot Order Form

According to the Paperwork Reduction Act of 1995, an agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0579-0335. The time required to complete this information collection is estimated to average .065 hours per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information.								OMB Approved 0579-0335 EXP XX/XXXX
United States Department of Agriculture Animal and plant health inspection service Wildlife services Pocatello supply depot order form				Through: (Name, Address, and Telephone of State Director)
Please furnish in accordance with instructions below the following items, and charge same to my account, payment there for to be made promptly upon delivery and receipt of invoice.
ship to (name and Address of Consignee)						via
Invoice to						pestocode applicatoe license number
charged to: (Show Appropriation Number, if applicable)
Item Number	Description of Supplies (for pesticides, list name and APHIS registration number)		Quantity		Size Containers		Unit Price and Unit		Amount
							$		$
							TOTAL		$
Requested by			Form prepared by
Address			Telephone number							Date
Signature of approving state director, WS, APHIS, USDA		date	for supply depot use only
			Invoice number				b/l number
mail or fax original to: pocatello supply depot 238 e. dillion street, pocatello, idaho 83201 commercial: (208) 236-6920 Fax: (208) 236-6922
			shipped by							date shipped
			Invoiced by

WS FORM 17 Previous edition may be used.

JAN 2011