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MEDICAL COLLEGE OF OHIO

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					             ____ Patient Care                                                                                      _____ Non-Patient Care
BIOMED USE ONLY
SOPI #                                   DATE RECEIVED                            W/O #                                        TECH INITIAL

TECH                                     DATE COMPLETE                            ID#                                          PURCHASE ORDER #




                                     THIS SECTION TO BE COMPLETED BY ORDERING DEPARTMENT
DEPT ACCT #                  REQUISITIONER’S NAME                    REQUISITION #                       DEPT EXT.                      END USE AREA

MODEL/CATALOG #                        DESCRIPTION                                                                        EST. COST $

                             THIS SECTION TO BE COMPLETED BY AUTHORIZED VENDOR/REPRESENTATIVE
                  VENDOR                          MANUFACTURER                    SERVICE SOURCE
NAME                                                 NAME                                                      NAME

ADDRESS                                              ADDRESS                                                   ADDRESS

CITY, STATE, ZIP                                     CITY, STATE, ZIP                                          CITY, STATE, ZIP

PHONE #                                              PHONE #                                                   PHONE #

FAX #                                                FAX #                                                     FAX #

SERVICE WITH CONTRACT (CIRCLE COVERAGE PROVIDED)

PARTS PROVIDED     24-HOUR SERVICE                BUSINESS HOURS ONLY                               PREVENTIVE/CALIBRATION ______TIMES/YEAR
ANNUAL CONTRACT EXPENSE                            RESPONSE TIME                                           COPY OF SERVICE CONTRACT PROVIDED
                                                                                                                         YES/NO
SERVICE WITHOUT CONTRACT:                                                                            PHONE # FOR TECHNICAL/OPERATOR ASSISTANCE
Hourly Rate:      Travel/Zone Charge   Response Time
SPECIALIZED TEST/CALIBRATION/REPAIR EQUIPMENT REQUIRED INCLUDING PRICE AND SUPPLIER (attach additional sheet if necessary):

PRODUCT COMPLIES WITH THE FOLLOWING CODES AND STANDARDS AS APPLY TO ITS INTENDED USE (circle):
    FCC      NFPA 99       UL 544     AAMI/ANSI       CSA         OTHER:
WARRANTY LENGTH      COPY OF WARRANTY ATTACHED                    Accessories/Disposables required for operation of equipment including catalog # and price.
 __________ Months |          YES / NO                          | (Attach additional sheet if necessary)
OPERATOR TRAINING WILL BE PROVIDED FOR                           AT (location)
$                               per person                     |                                                                          within the warranty period.
TECHNICAL SERVICE TRAINING WILL BE PROVIDED FOR                AT (location)
$                               per person                     |                                                                          within the warranty period.
                                      FACILITIES REQUIRED FOR OPERATION/SITE PREPARATION
Voltage                        Amperes                          Phase                               NEMA Plug                            Vacuum

Gas                                                  Cabling                                                    Exhaust

Ventilation/Cooling                                  Water & Drain                                              Are Required Utilities at End User Location Now?
                                                                                                                    Yes        No           Unknown
SIZE CRATED:                                                                      SIZE UNCRATED:
W            |L                 |H             | LBS                              W           |L                     |H                 | LBS


     No equipment will be delivered without at least one (1) complete copy of service documentation. Documentation is defined on the reverse,
      section 11.
     Complete replacement parts will be available for at least seven (7) years after expiration of the initial warranty period. Parts will be sold to
      the University of Toledo Medical Center their designated alternates by the closest/fastest source, including the local service representative.

THIS INFORMATION AS PROVIDED FOR THE PRODUCT ABOVE IS ACCURATE AND CONDITIONS ON THE REVERSE
ARE ACCEPTABLE. I HEREBY SIGN AS AN AUTHORIZED REPRESENTATIVE.
____________________________________________       _______________________________________            _____________________________________________
SIGNATURE                                          PRINT NAME                                         TITLE

____________________________________________      _______________________________________
REPRESENTING VENDOR                                DATE
                                        SELLER OBLIGATION MET OR PROVIDED FOR
BMES                                                DATE             FACILITIES MAINTENANCE                                 DATE

              SEE REVERSE SIDE FOR REQUIREMENTS OF SELLER OBLIGATION/PRODUCT INFORMATION
                                SELLER OBLIGATION / PRODUCT INFORMATION

NON-PATIENT CARE AND PATIENT CARE EQUIPMENT
1.     There will be support personnel available from the vendor/manufacturer VIA telephone during normal business hours to
       assist University of Toledo Medical Center(UTMC) personnel with operational and technical advice. There will be no charge
       for this service unless stated.

2.     Any specialized test equipment, interconnection cabling, extender cards or specialized test devices necessary for the use,
       preventive maintenance, calibration or repair of the device by UTMC personnel will be itemized on this form showing
       purchase price and supplier.

3.     The vendor is responsible for installation and/or setup of their equipment. Any facilities such as vacuum, electrical power,
       compressed gas, water, drain, cooling, exhaust, etc. required for equipment operation will be stated on this form. Where
       necessary, such information will be supplied in sufficient detail to guide site preparation/renovation.

4.     A copy of the warranty will be provided. Warranty period and invoiced terms will not start until the product has been
       installed and operated sufficiently to verify operation in accordance with manufacturer specifications, applicable codes and
       standards, and that it provides such services/functions as indicated by the sales representative.

5.     UTMC has the right to use any service representative of his choosing, including in-house, third party or independent
       contractor. These representatives have the right to repair, install, calibrate, maintain or repair all models of equipment
       purchased from the vendor. UTMC’s representatives shall be afforded the privilege of ordering all necessary repair parts and
       components from the vendor for each model of equipment purchased at a fair market price.

6.     In the event that computer software or external devices are required for the operation, calibration or repair of the equipment,
       then the vendor shall make available to the UTMC any and all software and hardware at a fair market price. All subsequent
       updates for the software or hardware must be provided at a fair market price. The software may be in the form of ROM type
       memory, magnetic media, software transmitted via telephone, or any new formats not yet available that may be developed in
       the future. UTMC has the right to use and operate all hardware and software for the purposes of operating, repairing, or
       calibrating the equipment. UTMC has the right to allow its designated service representative to use all software for the repair
       and calibration of the equipment purchased.

7.     Part or all payment will be withheld until all conditions stated herein are met or provided for and the product is officially
       accepted.

PATIENT CARE EQUIPMENT ONLY
       IN ADDITION TO 1-7 ABOVE, THE FOLLOWING APPLY:

8.     On-site operator training will be provided by the vendor at no cost unless stated otherwise on this form.

9.     Technical service training will be made available to UTMC personnel or their designated alternates either on site or at
       the vendor’s/manufacturer’s location within the warranty period. Cost and location of such training will be stated on this
       form or will be provided at no expense.

10.    UTMC has the right to send its designated service representative to the manufacturer’s service training schools to receive
       sufficient, any or all, technical training to allow the representative to repair and calibrate the equipment purchased.

11.    Service Documentation is defined as: Operator’s manuals, service manuals, schematics, software, trouble-shooting guides,
       theory of operation, parts lists, recommended preventive maintenance/calibration procedures and other information as
       furnished to the manufacturer’s/vendor’s own service personnel. UTMC will receive at no additional cost, all updates and
       revisions of the manuals, schematics and documentation as they become available from the vendor, for each model of
       equipment purchased.
THE REVERSE SIDE OF THIS FORM MUST BE COMPLETED, SIGNED AND DATED BY THE SELLER
REPRESENTATIVE INDICATING UNDERSTANDING AND ACCEPTANCE OF THE ABOVE
GUIDELINES AND REQUIREMENTS.
                                             University of Toledo Medical Center
                                                 Purchasing Services Mail Stop 1077
                                                      3000 Arlington Avenue
                                                      Toledo, OH 43614-5807
(419) 383-3649   FAX (419) 383-6250
                                      Form 591

				
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