Lorem

GOVERNMENT PURCHASE CARD REQUEST FORM
Emergency request?

Vendor accepts GPC?

Tax exempt?

Approving Official
Control Number:

GPC Acct 33638

Y

N

N

Deliver to:
1 SOLRS / LGRM
514 Hamby Place
Hurlburt Field, FL 32544

Vendor Name
& Address:

Home Depot
414 Mary Ester Blvd NW
Fort Walton Beach, FL
32548

ECARS Required >$10 Commodities

Mandatory Source Available? N

N

Y

Y

Y

ADD/DEL ITEM NO SCHEDULE OF SUPPLIES/SERVICES QUANTITY UNIT AMOUNT

+
–

1 1 Gal. Dual Action Weed and Grass Killer
SKU 1008675765 3 EA $26.9700 $80.91

TOTAL $80.91

COORDINATION/APPROVAL REQUIRED PER AFI 64-117

Base Communications (e.g. IT/comms equipment/service related
N/A

Base Safety Office (e.g. ATV, new equipment, etc)
[email protected] N/A

Civil Engineering (CE)(e.g. construction, HAZMAT, Temp Storage)
[email protected] N/A

Base Library (e.g. magazines, text books, subscriptions, etc)
[email protected] N/A

Logistics (e.g. vehicles, vehicle-related service, lease, etc)
850-884-5311

N/A

Public Affairs (e.g. visual info, electronic digital imaging, etc)
[email protected] N/A

Medical Group (e.g. Medical Supplies)
usaf.hurlburt.1-somdg.mbx.1-somdg-medical-logistics-customer-ser@mail.mil

N/A

Base Education Office (e.g. training-related services/SF-182)
[email protected] N/A

Remarks

Version 20240213

Victor, Gabrielle L.

NAME OF APPROVING OFFICIAL SIGNATURE

By Signing below I am certifying this is not a split purchase

Cardholder Checklist:
Prior to purchase
___Utilize a purchase request form to obtain approval
___Are there mandatory sources (Department of the Air Force Launchpad – Home (dps.mil))
___Check for any required coordination (see 64-117 para 7.12)
___Verify the item(s) to be purchased are authorized using the GPC (see 64-117 para 8.1)
___Use a purchase log to track all purchases prior to expenditure to ensure fund availability
___Submit an ECARS prior to purchase if purchase exceeds applicable MPT ($10K commodity/$2.5K services/$2K
construction) (
___Ensure no tax is paid

After purchase
___Require requester to print/sign their name, date and write “received” on purchase receipt
___Notify appropriate agencies of pilferable/sensitive items and individual items valued over $5K
___Upload receipt and all supporting documentation (889, purchase request, any coordination) into US Bank
___Create/match orders and review/reconcile monthly statements three business days after each billing cycles close
(19th of each month)
___Retain records for the required 10 years

Approving Official Checklist:
Prior to purchase
___Review and approve all purchases to ensure sufficient funds are available and purchases are legal, proper, mission
essential and correct (purchase request form)
___Utilize the Express Contract Action Reporting System (ECARS) to review/approve purchases over the applicable
micro purchase threshold (MPT) ($10K commodity/$2.5K services/$2K construction)

After purchase
___Ensure all supporting documentation is loaded by CHs for each purchase in US Bank
___Ensure flagged transactions are addressed within the required 30 days in Insights on Demand (IoD)
___Review and approve managing account statements in US Bank within five business days after the billing cycles
close (19th of each month)’
___Ensure this form is uploaded by CHs for each purchase in US Bank

GOVERNMENT PURCHASE CARD REQUEST FORM

Emergency request?

Vendor accepts GPC?

Tax exempt?

Mandatory Source Available?

ADD/DEL

ITEM NO

SCHEDULE OF SUPPLIES/SERVICES

QUANTITY

UNIT

AMOUNT

TOTAL

COORDINATION/APPROVAL REQUIRED PER AFI 64-117

Base Communications (e.g. IT/comms equipment/service related

Base Safety Office (e.g. ATV, new equipment, etc)

[email protected]

Civil Engineering (CE)(e.g. construction, HAZMAT, Temp Storage)

[email protected]

Base Library (e.g. magazines, text books, subscriptions, etc)

[email protected]

Logistics (e.g. vehicles, vehicle-related service, lease, etc)

850-884-5311

Public Affairs (e.g. visual info, electronic digital imaging, etc) [email protected]

Medical Group (e.g. Medical Supplies)

usaf.hurlburt.1-somdg.mbx.1-somdg-medical-logistics-customer-ser@mail.mil

Base Education Office (e.g. training-related services/SF-182)

[email protected]

Version 20240213

NAME OF APPROVING OFFICIAL

SIGNATURE

By Signing below I am certifying this is not a split purchase

Cardholder Checklist:

Prior to purchase

___Utilize a purchase request form to obtain approval 

___Are there mandatory sources (Department of the Air Force Launchpad – Home (dps.mil))

___Check for any required coordination (see 64-117 para 7.12)

___Verify the item(s) to be purchased are authorized using the GPC (see 64-117 para 8.1)

___Use a purchase log to track all purchases prior to expenditure to ensure fund availability

___Submit an ECARS prior to purchase if purchase exceeds applicable MPT ($10K commodity/$2.5K services/$2K

      construction) (

___Ensure no tax is paid 

After purchase

___Require requester to print/sign their name, date and write “received” on purchase receipt 

___Notify appropriate agencies of pilferable/sensitive items and individual items valued over $5K

___Upload receipt and all supporting documentation (889, purchase request, any coordination) into US Bank 

___Create/match orders and review/reconcile monthly statements three business days after each billing cycles close

      (19th of each month) 

___Retain records for the required 10 years 

Approving Official Checklist:

Prior to purchase

___Review and approve all purchases to ensure sufficient funds are available and purchases are legal, proper, mission

     essential and correct (purchase request form)

___Utilize the Express Contract Action Reporting System (ECARS) to review/approve purchases over the applicable

     micro purchase threshold (MPT) ($10K commodity/$2.5K services/$2K construction)

After purchase

___Ensure all supporting documentation is loaded by CHs for each purchase in US Bank

___Ensure flagged transactions are addressed within the required 30 days in Insights on Demand (IoD) 

___Review and approve managing account statements in US Bank within five business days after the billing cycles

      close (19th of each month)’

___Ensure this form is uploaded by CHs for each purchase in US Bank

11.0.1.20130826.2.901444.899636