MO 300-0297i (6-08)

MISSOURI OFFICE OF ADMINISTRATION

STATE PRINTING CENTER

WAIVER

2733 MERCHANTS DRIVE

JEFFERSON CITY, MO 65109

PHONE (573) 751-3307

FAX (573) 526-7900

AGENCY CODE (SAM II)

ORGANIZATION CODE

AGENCY NAME

QUANTITY

DESCRIPTION

REQUESTED BY

REQUESTOR'S TELEPHONE NUMBER

REQUESTOR'S E-MAIL ADDRESS

SPECIFICATIONS

REASON FOR WAIVER

FISCAL YEAR

WAIVER DATE

AMOUNT

VENDOR

COMMENTS

FOR SPC USE ONLY

WAIVER NUMBER

P09