Procurement Intake Form
Department
Please provide the information about the department.
Contact Person Name
*
First Name
Last Name
Please indicate contact person's title.
*
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Supplier
Please provide the available information about the supplier.
Supplier Name
First Name
Last Name
Supplier Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Contract Start Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Contract End Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
One or more of the following items are expected to be purchased as part of this procurement.
*
Rows
Expected to Purchase
Not Expected to Purchase
Capital Equipment
1
2
Services for installation, implementation, and integration
3
4
Various (e.g. furniture, hardware, general services etc.)
5
6
Goods to Consume
7
8
Medical Equipment
9
10
Licensing of Software
11
12
Maintenance / Service Plan / Warranty
13
14
Hardware and software for computers
15
16
Professional Services
17
18
Financing
19
20
Please enter the previous contract number if the service or product was already purchased.
Give a concise description of the items or services to be acquired, including their nature and purpose.
*
If available, include the quote(s) and/or proposed contract.
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