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Procurement Request Form

INSTRUCTIONS

Requestor Information

(a) Name of Request

(b) Phone Number

Email Address

(c) Procurement Request Tracking No.

(d) Date of Request

(e) Requestor's Division Value is not selected

(f) Attachment Types

Quotes

SOW

Product Specs

Upload Attachments

Procurement Information

(g) Type of Request

Hardware

Software

Continuation Maintenance

Services

Consulting

Supplies

Other

Specify "Other"

Total

Additional Procurement Information

(l) Was this request included in your original service cost pool?

Yes

No

(m) Service Category

(n) Is this project to be reimbursed by another agency?

Yes

No

(o) Agency/Org Value is not selected

(p) Contract Number

(q) Project Name

(r) Recommended Vendor

Vendor Address Look-Up

(r) Address Line 1

(r) Address Line 2

(r) City

(r) State

(r) Zip Code

(s) Name of person responsible for receipt

Ship To Address Look-Up

(s) Address Line 1

(s) Address Line 2

(s) City

(s) State

(s) Zip Code

(t) Briefly justify this procurement and state the impact of not approving this request

Cost Coding Information

PROCUREMENT REQUEST INSTRUCTIONS

Field	Instruction
a	The name of the person submitting the request.
b	The Phone number of the requestor.
c	Tracking No. Procurement Services will provide the requestor with the tracking number. All subsequent inquiries concerning the status or other questions pertaining to this request should use this number.
d	The date the Procurement Request is initiated.
e	OIT Division or EO225 Agency that the request is being submitted on behalf of.
f	Relevant attachments required for Procurement to be processed.
g	Type of request: indicate the basic nature of the item or service requested
h	The number of units (items, licenses, etc.) being requested
i	This should be a concise, but informative description of the items or services being requested. If more space is needed, please attach separate sheet with a complete description of the item or services (see Field f).
j	This is the unit price, based on the best vendor quote obtained.
k	This is the cost, based on the best vendor quote obtained. It is the unit price times the number of items being requested.
l	Were the items or services requested part of your original service cost pool?
m	Service Category of original service cost pool
n	Is project being reimbursed by another agency?
o	If another agency is funding this procurement via a fund transfer, please indicate the name of that agency and specific organization.
p	Vendor contract number if known.
q	Project name.
r	The name and address of a recommended vendor.
s	This is to reflect the specific contact person and delivery address to which the vendor is to deliver the product or provide the service.
t	A concise, but informative justification reflecting the need for this purchase.
u	OIT Manager’s approval signature.
v	OIT Senior Leadership Team’s approval signature.
w	OIT Chief Operating Officer’s approval signature.
x	OIT Contract Manager’s approval signature.
y	OIT Chief Financial Officer’s approval signature.
z	OIT Chief Technology Officer’s approval signature.
aa	OIT Procurement Service’s signature once Purchase Order has been executed.
ab	Attach the fully executed procurement package including Purchase Order.
ac	Reserved for pertinent comments by Procurement Services.
ad	The fiscal year of the procurement- to be assigned by Fiscal.
ae	The budget fiscal year of the procurement- to be assigned by Fiscal.
af	Appropriation Code- to be assigned by Fiscal.
ag	Cost Center Code- to be assigned by the Requesting Division.
ah	Activity Code- to be assigned by Fiscal.
ai	Object Code- to be assigned by Fiscal.
aj	Responsibility of requestor, Indicate proper mission by number: 1) IT Governance, Planning and Control 2) Maintaining a Secure Shared IT Infrastructure 3) Develop and Support Agency and Enterprise Applications 4) Supporting State and Local Emergency Telecom Services 5) Delivering Enterprise Services

Requester's Name

Date

Vendor Address Line 1 and 2

Vendor City-State-Zip Code

Ship To Address Line 1 and 2

Ship To City-State-Zip Code

Row 1:

procurement 1.1 - Quantity

procurement 1.5 - Desc

procurement 1.6 - Price

procurement 1.7 - Total

Row 2:

procurement 2.1 - Quantity

procurement 2.5 - Desc

procurement 2.6 - Price

procurement 2.7 - Total

Row 3:

procurement 3.1 - Quantity

procurement 3.5 - Desc

procurement 3.6 - Price

procurement 3.7 - Total

Row 1:

billing code 1.1

billing code 1.2

billing code 1.3

billing code 1.4

billing code 1.5

billing code 1.6

billing code 1.7

Row 2:

billing code 2.1

billing code 2.2

billing code 2.3

billing code 2.4

billing code 2.5

billing code 2.6

billing code 2.7

Row 3:

billing code 3.1

billing code 3.2

billing code 3.3

billing code 3.4

billing code 3.5

billing code 3.6

billing code 3.7

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DEMO: NJOIT Procurement Request