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Account - {{slatwall.account.firstName}} {{slatwall.account.lastName}}


Contact Information

Order Recipient

Enter the name and contact information of the individual who will be receiving this order.

Phone Format: XXX-XXX-XXXX

Something's not right - make sure you have a contact name, phone number, and you've selected a shipping and billing address.

You can save this order as a quote to finish later, or you can continue with your payment and order information.

Order and Delivery Information

Charge Against

Statute Format: 'YYYY'
Item Format: 'Agency Code - Reference Code - Fund Code' (XXXX-XXX-XXXX)

Certification of Approval of Executive Officer (CA Form 65 Only)

I HEREBY CERTIFY, on my own personal knowledge, that this order for the purchase of the items specified above is issued in accordance with the procedure prescribed by law governing the purchase of such items for the State of California; that all such legal requirements have been fully complied with.

You can save this order as a quote to finish later, or you can review your order on the next page before you place it.

Order Summary

Subtotal {{slatwall.cart.subtotal | currency}}
Discounts Applied - {{slatwall.cart.orderAndItemDiscountAmountTotal | currency}}
Tax {{slatwall.cart.taxTotal | currency}}
TOTAL {{slatwall.cart.calculatedTotal | currency}}

Billing & Payment

Billing Address

{{}}, {{orderPayment.billingAddress.stateCode}}

Payment Method

  • Purchase Order # {{slatwall.cart.orderPayments[$index].data.purchaseOrderNumber}}
  • Card #{{slatwall.cart.orderPayments[$index].data.creditCardLastFour}}

Shipping To

Order Recipient

{{slatwall.cart.contactPhone}}{{slatwall.cart.contactPhoneExtension ? ' Ext ' + slatwall.cart.contactPhoneExtension : ''}}

Shipping Address

{{}}, {{}}

Order Details




{{orderItem.sku.skuDefinition}} Item {{orderItem.sku.skuCode}}



{{orderItem.price |currency :(slatwall.cart.currencyCode == 'EUR'?'€':'$')}}
{{(childOrderItem.price * childOrderItem.quantity) | currency}}



Extended Price

{{(orderItem.price * orderItem.quantity) | currency}}

Order/Delivery Requirements


Request Prior Notification of Delivery


California State Agency Information

  • Agency / Department Billing Code

    {{ slatwall.getFormControlValue($parent.$parent.$parent.swForm, 'billingCode') }}
  • Element

    {{ slatwall.getFormControlValue($parent.$parent.$parent.swForm, 'element') }}
  • Task

    {{ slatwall.getFormControlValue($parent.$parent.$parent.swForm, 'task') }}
  • Program Category

    {{ slatwall.getFormControlValue($parent.$parent.$parent.swForm, 'programCategory') }}
  • Statute

    {{ slatwall.getFormControlValue($parent.$parent.$parent.swForm, 'statute') }}
  • Fund Title

    {{ slatwall.getFormControlValue($parent.$parent.$parent.swForm, 'fundTitle') }}
  • Contact Number

    {{ slatwall.getFormControlValue($parent.$parent.$parent.swForm, 'contractNumber') }}
  • Item

    {{ slatwall.getFormControlValue($parent.$parent.$parent.swForm, 'item') }}
  • Object Of Expenditure

    {{ slatwall.getFormControlValue($parent.$parent.$parent.swForm, 'objectOfExpenditure') }}
  • Chapter

    {{ slatwall.getFormControlValue($parent.$parent.$parent.swForm, 'chapter') }}
  • Certification Title

    {{ slatwall.getFormControlValue($parent.$parent.$parent.swForm, 'certificationTitle') }}
  • Authorizing Name

    {{ slatwall.getFormControlValue($parent.$parent.$parent.swForm, 'certificationName') }}

Yes, I am part of a California State Agency

No, I am not part of a California State Agency


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