HomeMy WebLinkAbout2007-060 Agrmt - Medtronic Physio Control
03/1,4/2007 13: 00 FAX 425 867 4539
O~/14/2007 09:28 FAX 5414885318
MEDTRONIC-TECHNICAL supp
AShland F1re
IgJUUUUUb
141 OOZ
..
:TECHNICAL SERVICE SUPPORT AGREEMENT ~
MedJ'Ponic
........_.-.. ".,....-.,'i!
Contract NumbGr. W> 07J N 14 J
Bnd UiEr II 001 89603
ASHLAND FIRE DEP,4.R.T1\reNT
455 SiSKIYOU aOULEV ARD
ASHLAND, OR 97~20
Bill To # 00 189602
ASHLAND PIRE DBPARTMENT
CYO ASHLAND-CITY HALL
20 EAST MAIN STREET
ASHLAND, OR. 97520
This Technical Service Support A~ent beains on 2/112007 md expirell On 1/3112008.
The dCllgn~tcd Covcn:cl Squipmem aDd/or software is lislri on Sdtedule A. Thil Tochnical Servi" Agreement
is subject to the Tenns md Conditions on the revor8Cl side oftbil dowment and 'any SGhcc1ult> B. if aUaohed.
lf any Data Management Support fUlc.t Upgrade Service is included on Schedule A then this T~hnlcal Service
Support AgrGCmlent I, also subjegt to Medtronic's Data Management SuppOrt and Upgrade
Service Terms and Conditio"s., rev 719fJ.l. .
Price of coverall: specified on Schcch,de A I. $8,290.00 per term, payable in Annuallnsrailmcnts.
Special Terms
15% OISCOUNT ON ACCBSSORmS
I S% DISCOUNT ON ALL BLECIRODES
\7~ DISCOUNT ON LP12 UPGRADES
SOUT.HBRN OREGON HUB
Accepted: MBDTRONIC Emergency lleIponse System., Inc.
~rlrY& /L, 1F:P.'~ A~
Title: ~ nt'mY7lJ~
Date: ~ / JLt J rFI-
, ,
Customer: ~'Ty ~ ;?s.ffUftNO
By: ~ _~~....~
Print: tA,e- r;..,\JII.A-~t:,
Title: ~"UI"-Ne4. lJ/~~~
Date: ~ /" I~"'"
,
Purchase OrdC1' Number:.
Territory Rap: W~55
Cole, Jon
Phone: 800-442.1142 x2844
FA'X: 800~712-3340
Cuatomer Coawx:
Graa Cue
Phone: ~4\-482-2770
FAX:
Rc~ce Number: NSS-0723
Priotcd: 312/2007
Rgnowal
Page I of S
V~/~~/~VVI ~~;V~ rftA ~~o 001 40~H
~UIKU~l~-ln~m'l~AL ~urr
Ashland Fire
"'=I uu"" uuu
IgJ 003
03/14/2007 09:28 FAX 5414885318
MEDTRONIC EMtSRGENCY R~PONse SV$TEMS. INC,
TECHNICAl.. SERVICE SuPPORT AGREEMENT TERMS AND CONDITIONS
ReNEWAL 1'eRMS
Medtronlc EmerglHlCl)' Re8paI_ SysfDms.InG.'a ("NedItOnIe") acceptanc:;e oICuS11:lf\'181'S Technical S.rvI= SUpport Ag....ment
Is expressly oondlllDned Of.! CUItOmer', UUf1liD the 1IInM eet for1h In Ihla documenlllnd Its attaetlmenu. MadtlOnic ~ to
fumilh lha fiIlNlcM onSel8d by CUltomer only on these Wme, and Culb'ner'8 aoceplilnce of any pQltion of 1he goods and .lIMen
~ Dy 1hI8 dOown8rlt sNIII Ulftftnn 1heIr IIaleP\arlce by Cuab:lmer. 1l1eee '-'"' c:anstilutll1he campIlIII8 agfHrnent belW8en tha
pal'lle. end they ,hall gowm *'Y conIIIcling or ~UllUI T8m11 on Cu5tQIn8fS purcllale order or an othoIr doQjmen" submitted to
Medtronlo by Cuceoll'ler. ",... telYM mllY nat De revt.ed In any mannllr wllhout the prior wriIt8n consent of .,.. afticIIr of Medt/'or1lc.
REPAIR SERVICES
If "Repair sarvk:elele _ipl8l:l. cubjM:l1D the ExcIwilonl identlfted below.1Ny .hlIlI include, for 1h, Q..Igna~ Cowred
Equipment. ell repelr p'~ and mater1ala reqund. .. required Medtnlnio HrvlClt tachnldan labor. and all related lnIvel
expense.. Foroff5i" (ahlp..lnllervices, unlt5wll bel rlItUmed to CusfDmel' by MedU'Onlcfrelght prepaid.
INSPECTION SERVICE;S
If "Inspection" "",Ieu ara designated, ,ublscl.lI:Ilhe I!xcIUIions- iclenllllaCl below. they shlll1 include, fartne deslgnllbld Covllf*l
Eq~nt. verl1lcaUon of prop.r inlULlll\ant callbraUon, v.,tllcsllan thIIl innument ~nlcal opera1iQl1t and output
mealUnllne"... oon&lsbmt with applicable produat epedI\ca1loM, per(onMrlce cf an elllctrlcal...ty c,.Ck in accon:lanca wilh
Nallonal F1nI and Prot8cIIon GWdeIIn85. .. ...Ired Medtronlo ..",l~ I8ehnIcI8n labor .nd al .....tIICI1ra\l8l....-. For
otralte (Ihlp-ln) services, unlls will be relUmed to cu.tGm8t by Mecltronlc fl'llght p~.
DOCU~ENTATION
FollowIng ud1 RepaIr..uor Inap8dioA. MecI1nlnio will provide Customer wIIh . writt8n NPOR cA adIonli laken Of reconvnendtd
and IdentlliClltiQn of any rnalaltals reptllCl8d or lIIOOlWnendad for ~llGllIlTWnl
LOANERS
If 8 Madllon1o plUduCl II designated a.a unlI 01 CovwIId Equipment tor Repair 8eMce. and n88ds 10 be remov..:! ~ service 10
completa rapalrl, an approprtate Loan.. unit wII be provkled. if av.UBbl..until1he removed unit II returned. Cutll:lmer a8IIUIMS
complete respon~bility ror 11'18 Loaner and lIhal ...Iutn 1M Loaner to tMdtronto In the ..me condition a. NceNecl. at Culto~
expense, upon tI'ItI earlier of 1he return of tI1II removed unit or MedtJgnicta raqlJllat
EXClUSIONS
Thl' Technical SeNlce Support AQreem&nt ~ M( lnc:Iude; supply or repeir of acceuories at diapo..blflS (e.g.. ~ti8nt cables.
reCOl'der paper. etc.); repair of damage C8lIIIed by III"', abUM. abnormlll o~t1ng condition., opel1Jtor arft2rs. and/or acts of God;
napaIrs to return en Illlitrumant to normal oplll8tlng eqlllpment at the time of lnitialclNlca by Medtronic uhder tills Technl~1
SeMce Suppgrt AQ...ment; c:aae chang..; r.lr or I'8p1acement Gt iIIIln& not orlglnaBy dIs1rIb~ ot Insialled by Medtronie;
WId exclusions on Sdledule B 10 1hIa Tedv1IcaI Servkle 5upport.Ag~ If lIllY, which apply 10 C<Mnd Equipment.
SCHEDULE SERVICES
OuIgnated Replllr lIl1d Il1lIpadiona ServIces will be perfonned at Iha deeignatBcllillNic:a ftquency and during designated servloe
hows elCC8pt where Ii8Mce ~ arelWnderad unavailable due to mancIIIIDfY ntMlg commltnNlnbi. in which cue Medtmnic
will plVVld.III"",,1II CCMIIIIGlt. Customer;.ta eMU" Covered E;quipm.ntl& avaIIIIbIe for Replllr86llJ1or IRIPfldlon .. KhedUled
tlm... If Covered Equipn","' i5 not.Vlllldlle aald1eduled and Cultomer NqUests adllltional sarvlcu to be ~8C1 or if MecftrarIig
I. Alqu.sted to perform R8p11ir or Inspection aerviGlIo nut eIUIgrated In thia T~I servlca Support AAl1Iemllnt (due to 1hc ~111 of
seMc:eS M1eoted, Ina1nJmanlllnvolved nQt being CClIMnId I!qulpment, -.qua. being outslde of deslgnatlld..rvIce frequerq' Of tlOUrll.
or .ppllcatlon at 1ha ExclusIorl5); Cu.mtner shall reimbuIW t.AIIcIIrClrIIe at M8dtronia's ltIndeRl I8bOr ratn I,.. 1 0% (including ovar1lme.
If iIpIX'ClpIfalc). plUlI sl1IndaId Sat prIeM for ntIated p..u .ncrmatedal.1Me1S%. plus KIIla11l8ve1 ClDaI8 IIQJl'I'llId.
PAVM!!NT
The c08t of ...... performed by Mecl1ronI~ shaD be payable by CUIlomBJ' wIUIln thirty (30) d.VI at Cuall:lmer's rec;alpt of MlIClttonlc'S
Invacs (or such 0Iher tarrM a. ~ confirms to Cultomer in wrI1Ina). In IIddiIion 1D the CGlt of IefVioH performed.
CUlItOmeI sh.. pay or nlIimb..... Uadtronic fur any ... .......d MBdtronlo. If" nurilber or c:onllgunJlicln cA Cover8d
Equipment Is altered during 1fte Term of 1hJs Tac;tInk:aI Service Support A9~.nt, the price of &ervle.1i &halt be sdJustvd ~ly.
WAAAANTV
MedU'OnIc WlIR8n1a Servic8e performed under lhI' Technlc:al 8eMce suppgrt~8nd ~ment pans proYlcled in
performing auCb Servlcn agelnst defeclB in ....1aIIIIl.nd wor1UMnshlp for ntnety (110) dlYS from ttle c1at& a $arvioe was perforrneII or ·
pari wn provided, Cullomers lal. rwrnedy sMU ~ .....-"tdng the atr.cllld unit andlor ~.OlIl11.nt of i1ny pan detormined ~ ~
defedlve, without sny addltlona' CUlIbner charge. plUVlded C\IldlNNI' notifies Mecltronlc of .ny .lI8gadl~' defec;:ljv8 oondldon
wllhln ten (10) c:UN1d.r dllYS of ita dJ.covery by Cusll:lrner. tMdtrOIlIc makos no oItwr watl'Mll... 8lqH'US or impIleCI. Including,
wKhout ....i..liDn. NO WAPNoNTY OF MERCHA/llTABILflY OR F1TNES8 POFt A PARTICULAR PURPOSE. AND IN NO evl!NT
SHALL M!.DTRONIC BE UABLE POR INCIDENTAL. CONSEClUENT1AL. SPECIAL, OR OTHER DAMAGES.
'R.efll1'eDCC Number: NSS~0723
Printed: 31'J.aOO7
Renewal
Page 2 of S
U3/14/2UU1 13:Ul ~'AA 425 ~U1 453U
03/14/2007 09:28FAI 5414885318
MJ:'.;JJ'l'KUN ll,;-'1'hlatl'H l,;AL e;uJ:'J:'
Ashland F1re
Il!.J UU't1 uuu
III 004
-.
TeRMINATlON .
Ellher party may terminate thla T8dlnIcaI 8ervlQII $UP'lllft Agreement 8t WIlly time upon s~ (60)lIays prior IIIflll.en notice to the
Olher. acept tMJt MllelrCll'\lc may IDnninaw II'IIs Technical s.rvtc8 SUpport AQrwmenl immediately LIpClI'Il!:uSf.OIIIen t.1Iu'" 10 make
Umeiy ptIY"'.,,1& for ..rvIces nlI1der8d und8r 1hIs Tec:tmIcIIl Servlca S\lppOO ~enl In the ...,.,t oI.."....llon. ClJlIklmer .hell
be oblilil'lrad 10 ~mburse Medlmftlc for 1hIIt pclI1Ion 01'" designated po.. wI'I\dl correlp~ to ~at port.lon of the Term and !he
IICOpll of Services prvvidec:l pltor to the effectlvw II.. of ..".,.naUon. .
DeLAYS
Medtronig will not be Uable for any loll or dlImage of ~ kind dlM 10 1111 failu,. to plll'fonn or delays In Ita performance I1Ilulling
fIom."y QUO beyond Its I'eIIlClllable contrd. Including. but not ~ 1D. ..- of God. labor diaputes,lalJor shortage.. tha
Mqulnarnllnla of 8111 govemrnen18laulhorlt)'. ,.,.... dvll unrut. ~ In manulac:Un. ~1rin1J 8f1'/ requRd brIM or permit.
and Medlr'onlch lneblll" lD obtai1 goods Ii'am lis USUllleoun:e&. Ally such deIa)' u. not be considerell . bte8Ch of MedlJunlc'l
obllgationa and the perfonnlnllll 1Ia.... sI.n be 8ld8nded far!he Iqth of .UllI\ dalay.
MISCELLANEOUS
a) CUCfOmer Ig"'8I to not employ or offer em~ 10 anyone perfonnlng Bervlcea on MedlroniC'8 ba"aIf durlov the Term 01
1hIa TlIIChnklal ServIce Support Agreement odor one (1) yelIrfgIQwinQ ltIexplndion without Medtronlc's prtgr wriU8n COlIIIent.
b) 1hIs Ted'lnical S8IVIce SupportA&Jlw8m8nt. and lIlY relallld aIlIIgaIIon d olherperty. may not be lIRipd In whole or In part
w1lhOullhe prior wriIter\ ~ of lie oller ~.
c) Till righrs and obUgIIIOl'l5 di MedlrOnIc and CU&IDmet under thil Ted1nIcal Service Support AQrelltllQni shIIIl be govemed by
the laws of th8 Stalll In which the sef\llc;e i. pn:wIdad. All CCJfIW IlI1d .,nut Incurred by thl pravalllnl p.lrty IIIlal8d to
ttw.nron:ement of 1lI11ght$ unller l1'li1 document, including ..sonabIe atll:lmey'l fe... shall be ~llJ1bul"1ed by the other party.
...-......................0......-..................-...........................................................--..........-......................................................................
.....".............................................,..............._..........,.,.elld.."..................................................................................1..."..........
R.aCcronc:c Number: 1'155-07:23
Pri1wld: 3/"l/'2007
R.coowa'
pqe 3 of S
~~/14/2UU1 13:Ul t'AA 425 867 4539
03/14/2007 09:28 FAX 5414885318
IlliI>TKUNIC-T~CHNICAL supp
Ashland F1re
I{&J UUll/ UUO
It! 005
.... "...
.: -..
MEDTRONlC EMERGENCY RESPONSE SYSTEMS, INC.
TECHNICAL SERVICE SUPPORT AGREEMENT
SCBEnULE A
Contract Number:
Servic1n& R.ep: Cole, Jon, WENNSS
Distriet: ROCKY MOUNTAIN
Phone: 800-442-1142 x2844
PAX: 800-772-3340
Equipment Location: ASHLAND FIRE DEPARTMENT, 00189603
45S SlSKlYO'U BOULEVARD
ASHLAND, OR 97520
Scope Of Service Ship 111 Repair - 1 On Site Inspectioo pet year.M-P/8-S
Ref. E1fecdvo Expiration Total
Madel Put Number Serial N..... Line Dale OIIm l.,.lIIIdian6
L1PSl'~ 12 VLPl1-&-002104 I!SlIl4l0 3 21112007 1111/2001 I
LlFEPAQIll2 VT.P12..o:z..ocnl64 13591432- <4 211/2007 1131/2001 I
UFEPAQ 11 VLPl~-o2..oo2164 135""" 5 21112007 1/311200. 1
UiEPAK4l11 VLPl ;1-0;1.4)02164 13598434 6 21\/2007 1/3112008
UfUAKlIIll Vl."J2-~-o02I64 13808176 7 :UI{2007 11311%008
UI'EPAlC.e 12 VLP12-01-OO1164 13808110 Il 2111%007 11l1f1OUI
t.1F8PAKlI) 12 VLP 12-02-001164 13101111 II 1/11%00' lm/2001
LWtiP"q 12 VLP 12-02-002940 30466671 10 2/1/2J!07 1131/2008
l..wel'AK~ 12 VLPI2-02-002940 30491400 11 2/1/2007 1/3112008
Scope Of Service Ship 1n Reprir OnIy:M-F/8-S
Rat. Etf_va Expll1ltlon Total
Model PmNlDllbar Serial No-I- l.lnD ~ nua In,PIlcllons
BATTERY SUPPOR;t SYSTE1\of1 V9SS2-O'Z..ooDCI09 117S3334 1 1/111007 '''' /2008 0
SA. TIBRY SUPPORT SYSTEM. 2. VBBS2-G2-ClOOOO9 1l76J570 2 21112007 II) 112008 0
.... DCIlClIIClI m inYlllEOI')' line dial... cllul&ad slnc;. the last CQ1I1hIlt tiM.'i01l or addendum.
Reference Number: NSS-07:!3
Prlnt8d: 3rlJ2007
Renewal
Page 4 of 5
03/.141 ZOOI .13: U.1 l"A.A 4Zb ~Hj'{ 40311
'03/14/2007 09:28 FAX 5414~85318
M..I!:UT.l(UNIC-T~CH.N1(;AL :SUl'l'
Ashland Fire
It&J OODI OOD
ICI 006
"
...
.'
-.
MEDTRONlC EMERGENCY RESPONSE SYSTEMS, INC.
TECHNICAL SERVICE SUPPORT AGREEMENT
SCHEDULE B
LrFEPAK.lID 12 DEPlBRILLATOIUMONTl'OR
. AC tower Adapw ioclllded \Vbeo listclll on cquipmem: illVlDlOry (S~ A).
. DC Power Adaptm' included wen1ilted on cq1Iipmr:nt invc:rI.tory (Schedule A).
. DefibriUatoll*kUo n:pain are included (cxotudCl intl=ma1.lII.eriIizIbla aDd pcdiatrig paddles).
. CoIIImuakaticJal and Patillnl eable1 an excluded.
. PCM'ClA Moclems ale ClUlhadod.
. Thlrapy c..blCl an: I:KCluded.
. SpO:Z SeDson an: c:xcludc:4.
. Case CJaagcs ve 1llCC1~cd.
. Di5COW2t of 17% ft'om tho fleld ;n51a1l1ld Dst 1Iric:e fbr IlDY Cl.lJTCtlt andlor ruture lvallable ....IFEP AK~ 12 upgrade is
included. wbm Wtalled by ~tronic Tc:c:lmica1 Services.
. DiscaUlllll mar ftOl be combiDcd witb ~ olhllt II1Iec!a1lMD1, dtscoants anJ1Jor 1'fOmoDons.
Mcdtronic Paatpalc~. F~ 2, Ltfcpak SLA ud Lifepak NiCd BI.ttIIY
. CuslOmcr NtaW the'RllfPOnslbiUty to peIform. the battery mainIenlIIK:c ll1Id ~bl&liQl1 procedures out! nod in the
operating ins1nIction lDIDuallDd 10 replKe baDllria tbat do not JIIIS' die ccmditioDl oulliDcl1 u.ndeI' "Diacanting/
Recyclillg Bllueries." Batteries failiDj 10 JIIod baIu:ry perfo1'Dlll1CC: tests should be removed trODl .ervice and properly
discarded (rCC)'elcli).
. Tf cu.atomer provides cvidcDclc tha1. MedIroaic BaueIy Pak fails to meet !he pedmnauI:c teats noted "bove a:ndIor
the Battery Pair. . exceeds:Z YaI!, MClIitranic.hIll replaGi: Rid MD4lronic BatWY PlIk Oikc for like) .e. FASWAJ( ,
lor FASTPAK. FASTPAK2!or FASTPAIO. LTFBPAKSLA forLJIlSPAK SLA. orI.lJlEPAl<. NiOi fer LIPBPAK NiCd.
up to I maximum of 4 Madb'oak: Saltily rab ovt;ry two yeatS (incll1dl:q prio.r suppllli Plan periods) par LlFEP A:KJ>> 12.
detibrillltorlmomlUt (ij,1cd on Schadule A). ,To asist in proplll' reeyc1iD& IDd Rlnovsl oflow capaclty ba=1CJ,
replaced Baney rales become the proPerlY of Mcdtronic ad 1IWSt be ralWDed at the timo of exchange.
. . Only baberict mIIlU1lI&:tDnd by Medtrorric IJe covered under this Sc:rvillll Ap-eemem. Any batteries ftIllDl1filctured by
other 'O\lNal arc IllI.prsly excluded ft'om covld&fl IIIIdtIr this SccviQCI ^sr=mem. Medll'Otlic cannot ~uataI1!ee the
opllll'BtiOll, sa1'ccy and/or pc:rfonnance of OlD' prodUllt wbea opemiD& with a llon-Medrt01'lic ba~cry. !',cpairll and WpectlOflll
pcrfOlUled IWder 1bis ~aJl meet orilln'l cquipmgDt manu1llc:luren produce IIpCDifications oaly wIleD oplSnllina with
. Modtronic battery. Any rcpem. as ddea..liftllld by I Mcd1rOllio Service 1lepNseD1aIivc. rcsulamg trom the use oh
non-McdlTanic battery, wm be billod at our ~ 1JIl prica forplltls and labor,lncluding actuallnlWll c:barpJ
iJJcurred.
Lifepake12 Sof\wBnl t.Ipdaus
. Tf combined R.epair and InspCQti.oll scrvicct are desipalrid 01\ the Technical Service Support Agracmeot inventoT)'
tor Lifqlllk 12 units, at the customer', Nqucst. a Meda'cmk TeobDical S;rvices R.epresentauvi: 'POI in5b1J1 Litepalc: 12.
software updl\l:l5 at 110 addilianal cbaIp provided. it i, inItalled at IbG time of a TeSwarly sc:Mduled iwpclion.
In addition durina ,be tcnII of this a.gremwul, wIMrc .,. usembly IUCh &S I prlnla1 cinluit boazd must be raplaced in
ardcr lD InSl&lI (he DeW IOf\wan:. these DIIcmb1i_ may be plllObase4 by me custom<< at Il 50% discounl off' ena cUl'1'e1'lt
list price of a new UlaDb1y. Softwsre I1pdaw rcqulllwd \0 be m.mDed at a Wac other than !be reauJu1Y SGboclulcd
inspcc:tiort will be billed alS20S per anitpa- softwa upd&rc. The COlt oldie soflware updall:l will be billed on a
sepana: mvoiglJ.
. I!RepairoOmy .,nCllll are desipaud on cbc: Service Order b1vemmy for l.ifilpalt 12 lIDits. at the ~EOIJIQr's reqlielt
Il Medtto.nic TecbJiiIm S~ 1lepteIeDtalive wW iDsta1I & LiCepak 12 softW'IR uplSato III . discounted pdoc or S205 per
UDit per IlOfhwre updllre. In addition during the fImI of t1dI 1II'ccm.cDl. whete aD uHmbty lI\IQh 11$ a ptinted cin:ult bollJ'd
mllSl: be RP1accd in order to hlacall thG nvw software, t!IIIe .......u.. m->, be pun:blltd by we guslDn"C at a. 50% dlsco\1nl
off'lhe cumot lilIt price 01. _ assembly. The colt oCtile lO1lwue update wiD be billed on . scpanItc; i1Ivoica.
. DilllOunl$ may not be combined with II:l1'Y ot1Iet tped111m111. clbcgunbl tDdIor promouoT\S.
RefCTCT1ce Number: NS5-0n3
Printed: 3/212007
Renewal
Page 5 of S
~~,
CITY R~:rORDER'S COpy
CITY OF II. . .........
A~~;~~D ~ r' -
ASHLAND, OR 97520
(541) 488-5300
Page 1 / 1
07453
VENDOR:" 003977
MEDTRONIC PHYSIO CONTROL
12100 COLLECTIONS CENTER DRIVE
REMIT TO
CHICAGO, IL 60693
FOB Point:
Terms: Net
Req. Del. Date:
Speciallnst:
SHIP TO: Ashland Fire Department
(541) 482-2770
455 SISKIYOU BLVD
ASHLAND, OR 97520
Req. No.:
Dept.: FIRE & RESCUE
Contact: GreQ Case
Confirming? No
Contract Renewal- Heart Monitor
Service Support AQreement
8,290.00
Terms of AQreement
BeQins: 02/01/2007
Expires: 01/31/2008
BILL TO: Account Payable
20 EAST MAIN ST
541-552-2028
ASHLAND, OR 97520
SUBTOTAL
TAX
FREIGHT
TOTAL
VENDOR COPY
THIS REQUEST IS A:
o Change Order(existing PO #
RECE~\/ED
MAR 1 6 2007
A{"l-'nIJNi('\ plAV . -); "~
,IV I ..ll I v r\! AtJLt:.
Required Date of Delivery/Service:
elT YOf
ASHLAND
A request for a Purchase Order
REQUISITION FORM
Date of Request:
1"1EDTIft'N/e O1EJft56I/CY I'fE.5flJ1;'SE JY..$/ePf$
P. 0. t3PY q] C>O~
IfClJfl1ONO W.lt Of "80 7 S
1- g~~. 'I~~ - /1'12-
AJ/.D~_ f'Ap'/lIS"H (~2S) 8b7-lf/s-~
Vendor Name
Address
City, State, Zip
Telephone Number
Fax Number
Contact Name
SOLICITATION PROCESS
Small Procurement o Sole Source 0 Invitation to Bid
o Less than $5,000 o Written findings attached (Copies on file)
o Quotes (Not required)
CooDerative Procurement 0 Reauest for ProDosal
o State of OR1'NA contract (Copies on file)
Intermediate Procurement o Other government agency contract 0 SDecial1 ExemDt
o (3) Written Quotes ~ Copy of contract attached 0 Written findings attached
(Copies attached) 0
ls( Contract # ('t3 08/'1 .., 'II Emeraency
0 Written findings attached
Description of SERVICES
f{UFiVAt,/C!(W77d11E a~,4l7 FP/? 116/I/(T /lRh'//V~
$61I1It!e $'t'(~Rr ~~i9V'?;
Per attached PROPOSAL
Item # Quantity
Unit
Description of MATERIALS
Unit Price
Total Cost
Project Number __ ____ - ___
D Per attached QUOTE
Account Number jjf-Q1-lJ. -W-~q~j~_O
* Items and services must be charged to the appropriate account numbers for the financials to reflect the actual expenditures accurately.
By signing this requisition form, I certify that the information provided above meets the City of Ashland public contracting requirements,
and the documentation ~uest.
Employee Signature: ~ Supervisor/Dept. Head Signature:
Updated on: 218/2007
G: FinanceIProcedurelAPIForms\8_Requisition form revised