Project Name:

___________________________________________________________________

RFP , Work Order, PO, SO, Number etc.

_____________________________

Quote Date:

_____________________

Supplier Name: ___________________________________________________________

Supplier contact name, phone & fax number: ____________________________________________

Lehigh contact name, phone & fax number: ______________________________________________

Taxable equipment & materials -

$____________________________________________U.S. Dollars

Brief description of materials included in Taxable

__________________________________________

_________________________________________________________________________________

_________________________________________________________________________________

Nontaxable equipment & materials -

$_________________________________________U.S. Dollars

Brief description of equipment and materials included as non-taxable

____________________________

__________________________________________________________________________________

__________________________________________________________________________________

Total tax to be paid by Lehigh & collected by supplier -

$___________________________U.S. Dollars

For Lehigh use only:

Lehigh Purchase Order Number:

___________________

Copy filed with Purchase Order (circle one)

Y N