Equipment Purchase Quotes by pfy99978

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									                                                 CERT EQUIPMENT---PURCHASE REQUEST FORM
                                       (Use this form to request the purchase of equipment)   ATTACH ALL VENDOR QUOTES!


Please fill out, print, & return to:
                                                           UASI GRANT                                                                  Today's Date           1/20/11
Anna Giacomini
East-West Gateway Council of Governments                   Line Number                                               SHIP TO THE FOLLOWING ADDRESS:
1 S. Memorial Dr., Suite 1600                              (Office Use Only)
St. Louis, MO 63102
                                                                                                                     Name

Point of Contact                                       Address                                                       Agency

Agency & Title                                         City, State, & Zip                                            Address

Team/Depart.                                           Phone Number                                                  City, State, & Zip


The costs provided on this form can be estimated costs.                                                              Phone Number



          ITEM INFORMATION (enter all requested information)                              VENDOR INFORMATION (enter all requested information)

ITEM #1
Category                                                                              Sole Vendor*                 State Contract*                  Total Cost

Quantity                                    Model #*                                  Company Name

Manufacturer*                                                                         Company Contact                                  Phone


Description**                                                                         Address

                                                                                      City, State, Zip
Justification

*Unless documentation is provided that a particular manufacturer & model                *Sole Vendor is defined as the only company that manufactures/sells a particular item.
number number is needed, we reserve the right to purchase acceptable                    Supporting documentation must be provided verifying the sole vendor status.
equivalents.                                                                            *Supporting documentation must be provided (i.e. copy of state contract or web
                                                                                        reference).
**Put additional description information in "Additional Notes."
                                   CERT EQUIPMENT---PURCHASE REQUEST FORM, con't.
                              (Use this form to request the purchase of equipment)   ATTACH ALL VENDOR QUOTES!




        ITEM INFORMATION (enter all requested information)                     VENDOR INFORMATION (enter all requested information)

ITEM #1, con't.
Additional Notes                                                           Sole Vendor*                 State Contract*                  Total Cost

                                                                           Company Name

                                                                           Company Contact                                  Phone

                                                                           Address

                                                                           City, State, Zip



                                                                           Sole Vendor*                 State Co ntract*                 Total Cost

                                                                           Company Name

                                                                           Company Contact                                  Phone

                                                                           Address

                                                                           City, State, Zip


                                                                             *Sole Vendor is defined as the only company that manufactures/sells a particular item.
                                                                             Supporting documentation must be provided verifying the sole vendor status.
                                                                             *Supporting documentation must be provided (i.e. copy of state contract or web
                                                                             reference).
                                           CERT EQUIPMENT---PURCHASE REQUEST FORM, con't.
                                     (Use this form to request the purchase of equipment)   ATTACH ALL VENDOR QUOTES!




         ITEM INFORMATION (enter all requested information)                             VENDOR INFORMATION (enter all requested information)

ITEM #2
Category                                                                            Sole Vendor*                 State Contract*                  Total Cost

Quantity                                  Model #*                                  Company Name

Manufacturer*                                                                       Company Contact                                  Phone


Description**                                                                       Address

                                                                                    City, State, Zip
Justifcation

Additional Notes                                                                    Sole Vendor*                 State Contract*                  Total Cost

                                                                                    Company Name

                                                                                    Company Contact                                  Phone

                                                                                    Address

                                                                                    City, State, Zip


*Unless documentation is provided that a particular manufacturer & model              *Sole Vendor is defined as the only company that manufactures/sells a particular item.
number number is needed, we reserve the right to purchase acceptable                  Supporting documentation must be provided verifying the sole vendor status.
equivalents.                                                                          *Supporting documentation must be provided (i.e. copy of state contract or web
                                                                                      reference).
**Put additional description information in "Additional Notes."
                                           CERT EQUIPMENT---PURCHASE REQUEST FORM, con't.
                                     (Use this form to request the purchase of equipment)   ATTACH ALL VENDOR QUOTES!




         ITEM INFORMATION (enter all requested information)                             VENDOR INFORMATION (enter all requested information)

ITEM #2, con't.
Additional Notes                                                                    Sole Vendor*                 State Contract*                  Total Cost

                                                                                    Company Name

                                                                                    Company Contact                                  Phone

                                                                                    Address

                                                                                    City, State, Zip


ITEM #3
Category                                                                            Sole Vendor*                 State Contract*                  Total Cost

Quantity                                  Model #*                                  Company Name

Manufacturer*                                                                       Company Contact                                  Phone


Description**                                                                       Address

                                                                                    City, State, Zip
Justifcation

*Unless documentation is provided that a particular manufacturer & model              *Sole Vendor is defined as the only company that manufactures/sells a particular item.
number number is needed, we reserve the right to purchase acceptable                  Supporting documentation must be provided verifying the sole vendor status.
equivalents.                                                                          *Supporting documentation must be provided (i.e. copy of state contract or web
                                                                                      reference).
**Put additional description information in "Additional Notes."
                                      CERT EQUIPMENT---PURCHASE REQUEST FORM, con't.
                                 (Use this form to request the purchase of equipment)   ATTACH ALL VENDOR QUOTES!




          ITEM INFORMATION (enter all requested information)                        VENDOR INFORMATION (enter all requested information)

 ITEM #3, con't.
  Additional Notes                                                              Sole Vendor*                 State Contract*                  Total Cost

                                                                                Company Name

                                                                                Company Contact                                  Phone

                                                                                Address

                                                                                City, State, Zip



                                                                                Sole Vender*                 State Contract*                  Total Cost

                                                                                Company Name

                                                                                Company Contact                                  Phone

                                                                                Address

                                                                                City, State, Zip


                                                                                  *Sole Vendor is defined as the only company that manufactures/sells a particular item.
                                                                                  Supporting documentation must be provided verifying the sole vendor status.
                                                                                  *Supporting documentation must be provided (i.e. copy of state contract or web
                                                                                  reference).


IF YOU HAVE ADDITIONAL ITEMS USE THE ADDITIONAL ITEMS SHEETS FOR EACH ADDITIONAL ITEM.
                                           CERT EQUIPMENT---PURCHASE REQUEST FORM, con't.
                                     (Use this form to request the purchase of equipment)   ATTACH ALL VENDOR QUOTES!




         ITEM INFORMATION (enter all requested information)                             VENDOR INFORMATION (enter all requested information)

Addtional Items
Category                                                                            Sole Vendor*                 State Contract*                  Total Cost

Quantity                                  Model #*                                  Company Name

Manufacturer*                                                                       Company Contact                                  Phone


Description**                                                                       Address

                                                                                    City, State, Zip
Justifcation

Additional Notes                                                                    Sole Vendor*                 State Contract*                  Total Cost

                                                                                    Company Name

                                                                                    Company Contact                                  Phone

                                                                                    Address

                                                                                    City, State, Zip


*Unless documentation is provided that a particular manufacturer & model              *Sole Vendor is defined as the only company that manufactures/sells a particular item.
number number is needed, we reserve the right to purchase acceptable                  Supporting documentation must be provided verifying the sole vendor status.
equivalents.                                                                          *Supporting documentation must be provided (i.e. copy of state contract or web
                                                                                      reference).
**Put additional description information in "Additional Notes."
                                  CERT EQUIPMENT---PURCHASE REQUEST FORM, con't.
                             (Use this form to request the purchase of equipment)   ATTACH ALL VENDOR QUOTES!




        ITEM INFORMATION (enter all requested information)                      VENDOR INFORMATION (enter all requested information)

Additional Items, con't.
Additional Notes                                                            Sole Vendor*                 State Contract*                  Total Cost

                                                                            Company Name

                                                                            Company Contact                                  Phone

                                                                            Address

                                                                            City, State, Zip


                                                                              *Sole Vendor is defined as the only company that manufactures/sells a particular item.
                                                                              Supporting documentation must be provided verifying the sole vendor status.
                                                                              *Supporting documentation must be provided (i.e. copy of state contract or web
                                                                              reference).

								
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