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: Brad Bauman 608-265-1462 Section 3: Contract Information Contract Number: Supplier Name: Supplier ID Number: 17-5747 Factory Motor Parts; Kayser Ford Lincoln; Napa Auto Parts Commodity/Service Codes: 055-00; 998-09 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 01/09/17 01/08/20 2 years – Request for Bid/Proposal Number: 17-5747 ☑ 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: Brad Bauman Phone Number: 608-265-1462 E-Mail Address: Section 3: Contract Information Contract Number: Supplier Name: Supplier ID Number: 17-5747 Factory Motor Parts; Kayser Ford Lincoln; Napa Auto Parts Commodity/Service Codes: 055-00; 998-09 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: 01/09/17 – 01/08/20 Renewal Options: 2 years ☑ Competitively Bid Request for Bid/Proposal Number: 17-5747 ☐ 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.
5747piggybackform.docx