Request to commence negotiations per Public Contract Code § 6611 For use on qualifying information technology (IT) Goods and Services and Non-IT Goods acquisitions. Requesting Department Information Agency: Department (Includes Boards, Commissions, and Associations): Institution (if applicable): Department Contact Information Contact Name: Street Address: Telephone: ( ) FAX: Mailing Address: ( ) E-Mail: Description of the Procurement Base(s) for negotiations (see page 2), check all that Check type of procurement: apply PCC 6611 (a): 1 2 3 4 IT Goods and Services Non-IT Goods If using PCC 6611 (b) check this box: Describe the procurement, how it meets the and justify all the Bases for negotiations checked state’s needs above. (Use additional pages if needed, approval signatures must remain on this page). Estimated Contract Amount Term of the Contract $ Department Department of General Services ___________________________________________________ _____________________________________________________ Signature of Agency Secretary or Department Director or PCO and Date Signature of Deputy Director, Procurement Division ___________________________________________________ _____________________________________________________ Print or Type Name and title of Signatory Print or Type Name and Title of Signatory and Date Remit completed form to: Department of General Services Procurement Division Attn: Intake and Analysis Unit 707 Third Street, 2nd Floor, MS: 201 West Sacramento, CA 95605
Request to commence negotiations per Public Contract Code § 6611 For use on qualifying information technology (IT) Goods and Services and Non-IT Goods acquisitions. Requesting Department Information Agency: Department (Includes Boards, Commissions, and Associations): Institution (if applicable): Department Contact Information Contact Name: Street Address: Telephone: ( ) FAX: ( ) Mailing Address: E-Mail: Description of the Procurement Base(s) for negotiations (see page 2), check all that apply PCC 6611 (a): 1 2 3 4 If using PCC 6611 (b) check this box: Check type of procurement: IT Goods and Services Non-IT Goods Describe the procurement, how it meets the state’s needs and justify all the Bases for negotiations checked above. (Use additional pages if needed, approval signatures must remain on this page). Estimated Contract Amount $ Term of the Contract Department ___________________________________________________ Signature of Agency Secretary or Department Director or PCO and Date ___________________________________________________ Print or Type Name and title of Signatory Department of General Services _____________________________________________________ Signature of Deputy Director, Procurement Division _____________________________________________________ Print or Type Name and Title of Signatory and Date Remit completed form to: Department of General Services Procurement Division Attn: Intake and Analysis Unit 707 Third Street, 2nd Floor, MS: 201 West Sacramento, CA 95605
gspd13-003.docx