THE UNIVERSITY OF TEXAS-HOUSTON
HEALTH SCIENCE CENTER

RETURN MERCHANDISE FORM
(Instructions:  Fill out form, print, acquire signature then turn in to Financial Office )

PART I.  To be completed by the Department and submitted to Purchasing DOCID # 
Date:
 Original P.O.
 Acct.# to be charged:

Dept.: 
Contact Person: 

Phone #: 

       Ship to:

 Merchandise to be picked up from:

Building:

Room:

Description of Item(s)


Catalog/Serial/Part No.
(Per Original P.O.)


UTHSC-H Inv. No.
(If Applicable)

To be completed by the Returning Department
Reason for Return:		 NOTE:  If merchandise cannot be returned at vendor's expense, please
indicate account number to be charged:  
Defective Merchandise Wrong Merchandise Delivered Duplicate
Shipment		 Authorized Departmental Signature:

_______________________________________________
Ship for Repair Ship only - no merchandise involved Other (Explain)
_______________		 PART II:  Approved by:  

Expeditor: 

Director:     
Authorized Return by Vendor:
   Representative: 

_______________________________
 
  Authorization #: 
  

Vendor's expense:  Yes        No
   Desired method of return: 

   Declared/Replacement Value: 
PART III.  To be completed by UT-HHSC Receiving Department
Merchandise received from: 


Date picked up:  		Date shipped: 

Method of shipment: 
         (No collect shipments via UPS or Parcel Post)