<p> Order Form No. ______(For CSL use only)</p><p>Public Health Commodity ORDER FORM</p><p>------SUBMITTED BY RECIPIENT (Mission point of contact): ------COUNTRY/CLIENT:</p><p>1. Order the following proposed shipments for CY______and CY______: Item Quantity Case Size Mode In-Country Receipt Date</p><p>2. Change the following previously ordered ROs or shipments: Requisition Order Current Revised Current Revised Item (RO) number Quantity Quantity Receipt Receipt Date Date</p><p>3. Cancel the following previously ordered ROs or shipments: Requisition Order Quantity Scheduled Receipt Item (RO) number Date</p><p>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. </p><p>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)</p><p>STREET ADDRESS: CONTACT NAME: PHONE: FAX: E-MAIL: Please indicate delivery requirements: Door-to-Door ( ) Door-to-Port ( )</p><p>Please indicate if you require pre-inspection: Yes ( ) No ( ) </p><p>Do you require a donation certificate: Yes ( ) No ( ) </p><p>Do you require a Certificate of Analysis or Conformance: Yes ( ) No ( )</p><p>Can your shipments be consolidated with other recipients: Yes ( ) No ( )</p><p>Please indicate if you require an import approval before shipping? Yes ( ) No ( )</p><p>SHIPMENT INSTRUCTIONS : Please indicate any additional shipping documents, special carton markings or special handling requirements. </p><p>Comments:______For CSL use ONLY Date Approved: ______CSL Commodity PEPFAR Pop. Funds ______Donation Funds Funds</p><p>CSL approves the above order. Please notify CSL immediately if any changes are made to this order.</p><p>______Date Signature of CSL Country Backstop </p><p>FOR JSI use ONLY</p><p>This order has been entered, see attached Requisition Order Confirmation Report. Notes: ______Order Form No. ______(For CSL use only)</p><p>______Date JSI Signature </p>