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

Attach Quote*

Total Contract Amount*

Enter as $ ##,###.##

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Department*

Building Department Community Preservation Committee (CPC) DPW – Administration DPW – Building Maintenance DPW – Engineering DPW – Fleet DPW – Highway DPW – Parks DPW – RTS DPW – Sewer DPW – Water Finance Department Fire Department HHS - Health Human Resources (Town Manager) HHS - Senior Services HHS - Veterans Services HHS - Youth Services Legal Library Memorial Park Trustees Municipal Parking Park & Recreation Planning & Community Development Police Department Building Design and Construction Town Clerk Town Manager

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