**FERMILAB/KNIPPEN\'S SHOES SAFETY TOE FOOTWEAR REQUEST**

**P.O. Number 557046**

+---------+-------------------------------+---+-------+---+------------+
| E       |                               | I |       | E |            |
| mployee |                               | D |       | x |            |
| Name    |                               | # |       | t |            |
|         |                               |   |       | . |            |
+---------+-------------------------------+---+-------+---+------------+

Expenditure Organization
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Project #\_\_\_\_\_\_\_\_\_\_\_\_\_\_Task#
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**This employee is to be provided with [one]{.underline} pair of ANSI
Class 75 safety toe footwear as indicated below.**

**The supervisor must sign this request.**

**[INSTRUCTIONS FOR OBTAINING SAFETY TOE FOOTWEAR]{.underline}**

> 1\. Fill out the information above, including your task number and
> project number, for one pair of ANSI Class 75 safety toe footwear. The
> form must be signed by your supervisor, and others, as indicated. A
> [separate form]{.underline} is required for [each]{.underline} pair of
> safety toe footwear you require. **Please make and/or keep a copy of
> completed form for your records.**
>
> 2\. Bring this form and your Fermilab I.D. card with you to order your
> safety toe footwear. The vendor \"shoe-mobile\" is available in the
> parking lot behind Industrial Center Building every Tuesday from 8:00
> a.m. to 4:00 p.m. (closed for lunch from 11:30 a.m. to 12:30 p.m.).
>
> 3\. If you choose a style that costs more than the \$85 allocated by
> Fermilab, you are responsible to pay the additional amount at the time
> the order is submitted. Make check or money order payable to
> "Knippen's Shoes." (Note: The Lab will pay the additional cost for
> medically prescribed and occupationally required corrections.)
>
> 4\. Many styles are stocked in the shoe-mobile and can be picked up
> immediately upon placement of the order. Other footwear will be
> delivered to the shoe-mobile within two weeks and can be picked up at
> that time. Please check with the vendor about delivery times when you
> place your order. **If you have any questions, contact the ES&H
> Section at Ext. 3482.**

+---------------------------------------------------------+------------+
|   ----                                                  | Date       |
| ------------------------- ----- -------- ------ ------- | \_\_\_\_   |
|                                 ID#            Ext.     | \_\_\_\_\_ |
|                                                         | \_\_\_\_\_ |
|   ----                                                  |            |
| ------------------------- ----- -------- ------ ------- |            |
|                                                         |            |
| Supervisor's Signature                                  |            |
+---------------------------------------------------------+------------+

**In addition, the Fermilab occupational medicine director must sign
this form for footwear requiring medically‑prescribed corrections.**

**Medically prescribed corrections required (describe):**

FNAL Occupational Medicine Director\'s Signature & ID# Date

**The division/section safety officer must sign this form for footwear
requiring unusual occupationally‑required options.**

**Unusual occupationally required options required (describe):**

Division/Section Safety Officer\'s Signature & ID# Date

  ------------------------------------------------------------ ------------------------------------------------------------------------------
  **[TO BE FILLED OUT BY KNIPPEN REPRESENTATIVE                
  ONLY]{.underline}**                                          

                                                               

  DATE:                                                        
  \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_   

                                                               

  SHOE STYLE: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_     SIZE:\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

                                                               

  KNIPPEN PRICE:                                               \$\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

  AMOUNT COVERED BY FERMILAB:                                  \$\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
  ------------------------------------------------------------ ------------------------------------------------------------------------------