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EXHIBIT A -3 <br /> SAMPLE PURCHASE ORDER FORM <br /> [Do NOT use this paper form. Use the electronic version downloadable from <br /> http://wvvw.bayareatrashtracker.org/content/contract-resources] <br /> USE ONE FORM PER VENDOR. ATTACH ADDITIONAL SHEETS, SHOWING ALL INSTALLATION <br /> LOCATIONS, AS NECESSARY. <br /> THIS PURCHASE ORDER IS NOT FINAL UNTIL APPROVED BY ABAG <br /> P.O. No. (city /county name + 4 -digit number) <br /> Date <br /> Municipality Information Vendor information <br /> City/County: Company name: <br /> Attention: Vendor Tax ID: <br /> Address Attention: <br /> Address <br /> City Zip City State Zip <br /> Phone Fax Phone Fax <br /> Email Email <br /> Order Details (Use one row for each installation. Add rows as necessary) <br /> Line # Device Description / Model Location* Delivery Install / Price <br /> number Date Noninstall <br /> 1 <br /> 2 <br /> Tax <br /> Shipping /delivery, if applicable <br /> TOTAL <br /> * Location must be specific (SW corner 6"' St. & Main or GPS coordinates). See online form for specification <br /> instructions. <br /> Special Conditions * *: <br /> * *Attach additional sheets, showing all special conditions, as necessary. <br /> Approved by Date: <br /> (Signature of authorized Representative, Participating Entity) <br /> Name (print) Phone <br /> Approved by Date: <br /> (Signature of device vendor representative) <br /> Name (print) Phone <br /> Approved by Date: <br /> (ABAG) <br /> OWP # 102147 <br /> 10 <br />