NON-SMART SOURCE VENDOR

AND / OR
A Print Process Manager
NEW ITEM FORM
Please email completed form to your Smart Source Onsite Contact(s):
Mansfield Corporate Surgical Devices Respiratory and Monitoring Imaging
Patient Care and Safety Prod Cinda Wood Energy-Based Devices Pharma Brand / Generic
Medical Supplies 203-845-4402 Anne Walters Marie Diekemper
Jayne Bennett cwood@smartsourcellc.com 303-581-7086 314-654-3479
508-452-4119 awalters@smartsourcellc.com mdiekemper@smartsourcellc.com
jbennett@smartsourcellc.com

CLIENT NAME Energy-Based Devices (7408)

CONTACT NAME Andrea Babb CONTACT PHONE

NEW ITEM NON SS VENDOR Today’s Date 06/25/10

ITEM INFORMATION
ITEM # R0008085 Rev Date Cost Center/GL 10820316
Description Clinical Article
Detailed Description:
Title: Operative Blood Loss Independently Predicts Recurrence and Survival After Resection of Hepatocellular Carcinoma

UM Type: Each Price Per UM 4.60

Qty Per UM 1 (Example: Each 1, Package 5)
* Copy of invoice/quote from vendor required

TIMING / QUANTITY INFORMATION

Expected Arrival Date 06/29/10 Expected Total Quantity 875

Customer PO or Reference Number

SITE INFORMATION
Item Owner Andrea Babb
ROP Qty ROP Days

Image Attached Yes No (if no, please provide sample to shoot)

Category Oncology Sub Category General Oncology
Restriction Qty 25
Post Value to Site (Charge Back) Yes No
Special Instructions:

FOR INTERNAL USE ONLY

PO # DB Date Four51 Date

COV-NISU (07/09)
PRINT CLEAR