Applicant / organization: __________________
Date: __________ Quote / account reference: __________
Product or service: _________________________________
Current quoted price: __________ Quantity: __________
Requested discount: __________ Proposed total: ______
Reason for request: _________________________________
Supporting information attached: ____________________
Requested validity period: __________________________
Applicant contact / signature: ______________________
OFFICE USE - Approved discount: __________
Decision / reason / authorized by / date: _____________