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SCCA Request
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State Contract Confirmatory Agreement (SCCA) Request Form
Purchasing
*
Equipment
Goods or Materials
Technology
Other Services
Professional Services
Trade Services
Town Assigned Contract #:
*
State Contract #
*
State Contract Title
*
State Contract Expires
*
This Agreement Expires
*
Vendor Name
*
Vendor Address
*
Vendor Telephone
*
Primary Contact Person/Title
*
Primary Contact Telephone Number
*
Primary Contact Email Address
Date of Vendor's Quote
*
Name of the Individual Authorized to Sign the SCCA on behalf of the Vendor
Position Title of the Authorized Individual
Authorized Signer Email Address
Reserved
Total Contract Amount
*
Enter as $ ##,###.##
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Department
*
Building Department
Community Preservation Committee (CPC)
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DPW – Building Maintenance
DPW – Engineering
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DPW – Parks
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DPW – Sewer
DPW – Water
Finance Department
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HHS - Health
Human Resources (Town Manager)
HHS - Senior Services
HHS - Veterans Services
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Memorial Park Trustees
Municipal Parking
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Building Design and Construction
Town Clerk
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Town Project Title
*
Primary Town Contact Person/Title
*
Funding Source for the Procurement
*
Capital Project Appropriation
Department Operating Budget
Donation
Federal or State Grant Funds
Other Town Meeting Appropriation
Revolving Fund
Special Revolving Fund
Trust Fund
Multiple Sources (explain)
Additional Information:
Authorization Code
*
rev 08/22/2011; 06/29/2013; 11/12/2015; 08/25/2017; 12/17/2019; 08/17/2020; 11/26/2021
* indicates required fields.
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