Contract Number Request Form

Type of Request*

Agreement Number (SBP) Confirmatory Agreement Number (Please Complete Section II as Well) Contract Number for a Bid Contract Number for a Quote Emergency Procurement Number

Contract Type*

Equipment Only (Chapter 30B) Goods, Materials, or Supplies (Chapter 30B) Services (Chapter 30B) Technology Services (Software or Technical Support) Architect, Designer, or Engineering Services for a Public Building (Chapter 7) Engineering Services NOT for a Public Building Building Construction or Repair Services Non-Building Construction or Repair Services (Public Works) Sale of Surplus Equipment Other (Explain)

Title for the Contract*

Term*

Stand Alone (one time) One Year or Less Multi-Year

Effective Date of the Contract*

Estimated Total Value*

Less than $3,000 More than $3,000 but less than $9,999 More than $9,999 but less than $49,999 More than $49,999 but less than $99,999 More than $99,999 but less than $1,000,000 More than $1,000,000

Requesting Department*

Building Department Commission on Disabilities Community Preservation Committee (CPC) DPW - Administration DPW – Building Maintenance DPW – Drains DPW – Engineering DPW – Fleet DPW – Highway DPW – Parks & Forestry DPW – Recycling & Solid Waste DPW – Sewer DPW – Snow and Ice DPW – Water Finance Department All Divisions Fire Department Health & Human Services - Public Health Health & Human Services - Senior Services Health & Human Services - Veterans Services Health & Human Services - Youth & Family Services Town Counsel Library Municipal Parking Park & Recreation Planning & Community Development Police Department Building Design & Construction Town Clerk Town Manager School Department Other (explain in the description box)

Funding Source*

Capital Project Appropriation Department Operating Budget Financial Warrant Article Grant – Federal (explain) Grant – State (explain) Grant – Local (explain) No Cost Contract Other Source (explain)

Primary Category *

Other (explain) Construction Services Design Services for a Building Engineering Services for a Non-Building Project Equipment Purchase Building Repairs Equipment Repairs Infrastructure Repairs (Roads, Sewers, Water systems) Parks and Fields Repairs Services - Professional or Technical Services - Software Services - Training Supplies and Materials Only Energy Related (Fuel, Oil, Natural Gas, Electric)

Additional Information*

Authorization Code*

Section II
Required for All Confirmatory Agreements

Have You Forwarded the Vendor's Quote to Procurement*

Yes No NO, this is NOT a request for a confirmatory agreement

Which Purchasing Group Does This Contract Relate*

State Contract (COMMBUYS) Greater Boston Police Council, Inc. (GBPC) Metropolitan Area Planning Council (MAPC) Savvik Buying Group (SBG) Sourcewell (SW) Cooperative Purchasing Massachusetts Higher Education Consortium (MHEC) OMNIA Partners (OP) New 12-07-2022 THIS is not a cooperative contract purchase

Name of the Primary Contact for Town

Vendor Name

State or Cooperative Contract #

State or Cooperative Contract Title

State or Cooperative Contract Expires

Vendor Street Address

Vendor Address (City/Town, State, Zip Code)

Vendor Telephone

Primary Contact Person/Title

Primary Contact Telephone Number

Primary Contact Email Address

Name of the Individual Authorized to Sign the SCCA on behalf of the Vendor

Position Title of the Individual Authorized to Sign the SCCA

Email Address of the Individual Authorized to Sign the SCCA

Is This a Request for a Confirmatory Agreement?*

Yes No

06/29/2013 rev 06/11/2014 rev 11/10/2014 rev 09/24/2015 rev 11/12/2015 rev 03/08/2016 rev 06/30/2016 rev 08/25/2017 rev 01/03/2018 rev 01/26/2019; rev 12/17/2019; rev 05/29/2020; rev 07/06/2020; rev 06/01/2022; rev 06/29/2022; rev 09/13/2022; rev 10/08/2022