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					                                                FACILITIES

                               Request for Vice Chancellor Approval for
       PROFESSIONAL/TECHNICAL CONTRACTS/AMENDMENTS AND PURCHASES:
               OVER $100,000 or CONTINUE BEYOND 5 YEARS or SOLE SOURCE
       The following is being provided in accordance with MnSCU System Procedure 5.14.2, Part
                         2 and Part 6 Subpart B; and 5.14.5, Part 4, subpart D.



1. CONTRACT ADMINISTRATOR/REQUESTOR:


        Name: ____________________________                       Institution: _________________________


        Email: ____________________________                      Phone: ____________________________


        Project Title: __________________________________________________________________


2. DATE OF REQUEST:____________________

3. EXPLAIN THE NEED FOR P/T CONTRACT/AMENDMENT OR PURCHASE:_____________
________________________________________________________________________________

4. VENDOR OR OTHER PARTY TO CONTRACT: _____________________________________

5. VENDOR SELECTION PROCESS:

        Public Notice of Request for Bids or Proposals
                Date: _________________________
                   Method of Notice & Number of responses:_________________________________

        □ Sole Source
                   Reason: ___________________________________________________________

6. VENDOR CONTRACT TERM GREATER THAN 5 YEARS?
        □ No
        □ Yes, this contract/amendments have a term greater than five years.
                   Reason: __________________________________________________________

7. ESTIMATED COST OF CONTRACT/AMENDMENT OR PURCHASE:
        □ New contract or purchase
                   Proposed value of contract or purchase                      $ ___________
        □ Contract extension:
                   Existing contracts/amendments or purchase amount            $ ___________
                   Proposed contracts/amendments or purchase amount            $ ___________
                   Total contract/amendment or purchase amount                 $ ___________




Revised 5/7/2012
                                          FACILITIES




8. FUNDS ARE AVAILABLE IN COST CENTER NUMBER/FUNDING TYPE _______________________



   APPROVED: _____________                  OR             DISAPPROVED: ____________

   BY: __________________________________
       Vice Chancellor - Chief Financial Officer
   DATE:_________________________________
   REASON FOR DISAPPROVAL:___________________________________________

Original form will be retained by the Finance Division and a copy returned to the requestor.




Revised 5/7/2012
                                             FACILITIES

                                       INSTRUCTIONS for
                             Request for Vice Chancellor Approval for
     PROFESSIONAL/TECHNICAL CONTRACTS/AMENDMENTS AND PURCHASES:
            OVER $100,000 or CONTINUE BEYOND 5 YEARS or SOLE SOURCE
    The following is being provided in accordance with MnSCU System Procedure 5.14.2, Part 2
                        and Part 6 Subpart B; and 5.14.5, Part 4, subpart D.


1. CONTRACT ADMINISTRATOR/REQUESTOR:
     Please indicate the employee name requesting approval for the purchase or contract, Institution
      name and location, employee’s email address and phone number. Provide a brief title for the
      project. Note that requestor must have authority to sign proposed contract/amendment.

2. DATE OF REQUEST:
     List the date of the request.

3. EXPLAIN THE NEED FOR PURCHASE OR CONTRACT:
     Indicate the need and benefit received for proposed contract/amendment or purchase. Attach
      additional sheet if needed.

4. VENDOR OR OTHER PARTY TO CONTRACT:
     List vendor if one has been selected. If vendor has not been selected, indicate the selection
      method that will be used.

5. VENDOR SELECTION PROCESS:
     If using a Public Notice of Request for Bids or Proposals, indicate the date and method of notice.
      The method of notice may be an official newspaper such as the State Register.
     If the vendor has been determined to be Sole Source, indicate the reason. Attach additional sheet
      if needed to explain. Documentation on the search and reason for the sole source determination
      must be kept on file. The determination for sole source must satisfy the requirements of the State
      of Minnesota Single Source Policy.

6. VENDOR CONTRACT TERM GREATER THAN 5 YEARS?
     Indicate if proposed contract, consecutive contracts, or contract with amendments has a term
      greater than five years and list reason for the extension.

7. ESTIMATED COST OF CONTRACT/AMENDMENT OR PURCHASE:
     If request is for a new contract or purchase, indicate proposed amount of contract (include
       contingency if applicable).
     If request is for a contract extension, identify amount of all existing contracts and amendments
       with vendor applicable to this work activity/project. Also, indicate amount of all proposed
       contracts and amendments (include contingency if applicable). Indicate amount of proposed total
       of contracts and amendments.

8. FUNDS ARE AVAILABLE IN COST CENTER NUMBER
     Indicate the cost center(s) in which funds are available. If the purchase or contract is for a future
      fiscal year, indicate which cost center the funds will be available.

9. PROCESSING THIS REQUEST FOR VICE CHANCELLOR-FINANCE APPROVAL:
     Please send this request form to OOC Program Manager to initiate the processing of the form.
    Listing of Program Managers and assigned campuses is available at
    http://www.finance.mnscu.edu/facilities/design-construction/responsibilities/index.html. If approved
    by Vice Chancellor, a signed copy will be returned in an electronic format within 3 business days.



Revised 5/7/2012

				
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