Usaid Avian Influenza Stockpile

Order Form No. ______(For CSL use only)

Public Health Commodity ORDER FORM

------SUBMITTED BY RECIPIENT (Mission point of contact): ------COUNTRY/CLIENT:

1. Order the following proposed shipments for CY______and CY______: Item Quantity Case Size Mode In-Country Receipt Date

2. Change the following previously ordered ROs or shipments: Requisition Order Current Revised Current Revised Item (RO) number Quantity Quantity Receipt Receipt Date Date

3. Cancel the following previously ordered ROs or shipments: Requisition Order Quantity Scheduled Receipt Item (RO) number Date

Please indicate if existing address information should be used: Yes ( ) No ( ) OR (Available on the web site: jsi.deliver.com/mycommodities) If not, please specify address and shipping information below. Fill out one form per recipient.

CONSIGNEE :( Information must be provided in full, in order to fulfill request). NAME: STREET ADDRESS: CONTACT NAME: PHONE: FAX: E-MAIL: SHIP TO ADDRESS: (RECIPIENT/DELIVERY DESTINATION) NAME: Order Form No. ______(For CSL use only)

STREET ADDRESS: CONTACT NAME: PHONE: FAX: E-MAIL: Please indicate delivery requirements: Door-to-Door ( ) Door-to-Port ( )

Please indicate if you require pre-inspection: Yes ( ) No ( )

Do you require a donation certificate: Yes ( ) No ( )

Do you require a Certificate of Analysis or Conformance: Yes ( ) No ( )

Can your shipments be consolidated with other recipients: Yes ( ) No ( )

Please indicate if you require an import approval before shipping? Yes ( ) No ( )

SHIPMENT INSTRUCTIONS : Please indicate any additional shipping documents, special carton markings or special handling requirements.

Comments:______For CSL use ONLY Date Approved: ______CSL Commodity PEPFAR Pop. Funds ______Donation Funds Funds

CSL approves the above order. Please notify CSL immediately if any changes are made to this order.

______Date Signature of CSL Country Backstop

FOR JSI use ONLY

This order has been entered, see attached Requisition Order Confirmation Report. Notes: ______Order Form No. ______(For CSL use only)

______Date JSI Signature