STAR Piggybacking Request Instructions: Send the completed form via e-mail to: Section 1: Agency Requesting Piggyback Agency Requesting Piggyback: Agency Business Unit Number: Agency Contact Name: Phone Number: E-Mail Address: ☑ My agency has notified the Originating/Contracting Agency identified in Section 2 below that we intend to use their contract and that they have agreed. Section 2: Originating/Contracting Agency Originating/Contracting Agency: Agency Business Unit Number: UW Madison Purchasing Services 28500 Originating/Contracting Agency Phone Number: E-Mail Address: Contact Name: Carla Parker 608-262-4516 Section 3: Contract Information Contract Number: Supplier Name: Supplier ID Number: 17-5994 PerkinElmer Health Sciences Inc. Commodity/Service Codes: 193-08; 193-22; 193-40 Estimated Annual Spend: $_____________ Section 4: Eligibility Check ☑ My agency has validated the following, and is in compliance with the requirements of of the State Procurement Manual. Contract Effective Dates: Renewal Options: ☑ Contract is Open 3/1/17 2/28/18 4 years – Request for Bid/Proposal Number: 17-5994 ☑ Competitively Bid ☐ Supplier(s) is/are not on the ☐ Supplier(s) is/are not on the . Impact, if any, on any new minority business enterprise, disabled veteran-owned business or work center: ☐ Contract scope matches my agency’s need. Description of the scope of the original procurement and how it corresponds to the community/service to be purchased: This document can be made available in alternate formats to individuals with disabilities upon request.
STAR Piggybacking Request Instructions: Send the completed form via e-mail to: Section 1: Agency Requesting Piggyback Agency Requesting Piggyback: Agency Business Unit Number: Agency Contact Name: Phone Number: E-Mail Address: ☑ My agency has notified the Originating/Contracting Agency identified in Section 2 below that we intend to use their contract and that they have agreed. Section 2: Originating/Contracting Agency Originating/Contracting Agency: UW Madison Purchasing Services Agency Business Unit Number: 28500 Originating/Contracting Agency Contact Name: Carla Parker Phone Number: 608-262-4516 E-Mail Address: Section 3: Contract Information Contract Number: Supplier Name: Supplier ID Number: 17-5994 PerkinElmer Health Sciences Inc. Commodity/Service Codes: 193-08; 193-22; 193-40 Estimated Annual Spend: $_____________ Section 4: Eligibility Check ☑ My agency has validated the following, and is in compliance with the requirements of of the State Procurement Manual. ☑ Contract is Open Contract Effective Dates: 3/1/17 – 2/28/18 Renewal Options: 4 years ☑ Competitively Bid Request for Bid/Proposal Number: 17-5994 ☐ Supplier(s) is/are not on the ☐ Supplier(s) is/are not on the . Impact, if any, on any new minority business enterprise, disabled veteran-owned business or work center: ☐ Contract scope matches my agency’s need. Description of the scope of the original procurement and how it corresponds to the community/service to be purchased: This document can be made available in alternate formats to individuals with disabilities upon request.
5994piggybackform.docx