ATTACHMENT 10 - VISN4 DME VA FORM FL 10-90 REQUEST TO SUBMIT QUOTATION.pdf

FL 10-90SEP 2008

VA FORM

In Reply Refer To:

DEPARTMENT OF VETERANS AFFAIRS

This letter is submitted to secure an estimate for the information listed on the attached. It does not constitute a purchase order; nor is it to be considered as authority for delivery or work to be started.

This letter authorizes you to contact the veteran listed on the attached for additional information and/or to schedule an appointment for evaluation. Based upon your assessment, you are required to provide us the most accurate estimate possible.

Your estimate is expected within five (5) business days from the date of this letter unless you notify the VA Approving Official.

Please fill out the attached and return via facsimile to the Department of Veterans Affairs facility indicated above. Consideration of the purchase of the item(s) listed in the attached will be made and, if approved, a purchase order will be prepared and forwarded to you. At that time, you are authorized to start work.

You may retain one copy of this letter and the attached for your files.

If you have any questions, please contact the VA Approving Official at the telephone number listed on the attached.

Sincerely, Attachment: VA Form FL 10-90

FL 10-90SEP 2008

VA FORM

SECTION I - (To be completed by requesting VA Facility)

REQUEST TO SUBMIT QUOTATION

INSTRUCTIONS: Please fill out vendor estimate in Section II below and submit to the requesting VA facility.

VENDOR REQUESTING VA FACILITY

Name:

Address:

Phone Number:

Fax Number:

Name:

Address:

Phone Number:

Fax Number:

Name:

Phone Number:

VETERAN INFORMATION

Your firm is being considered as a possible source for the following:

An estimate for the above listed items(s) is requested. YOUR QUOTATION DOES NOT CONSTITUTE A PURCHASE ORDER NOR IS IT TO BE CONSIDERED AS AUTHORITY FOR DELIVERY OR WORK TO BE STARTED. This request authorizes you to contact the above named veteran for additional information and/or to schedule an appointment for evaluation. Upon completion of the estimate, return via facsimile to the Department of Veterans Affairs facility indicated above. Your estimated is expected within 5 business days from the date of the request unless you notify the VA Approving Official.

Consideration of the purchase of the above will be made, and, if approved, a purchase order will be prepared and forwarded to you. You may retain a copy of this request for your files.

Name and Title of VA Approving Official Date SECTION II - VENDOR'S ESTIMATE (To be completed by Vendor)

Estimate should be itemized, separating materials from labor costs

HCPCS (if known) Item(s) or Service(s) Qty Unit Unit Cost Total Cost

DateName and Title of Company Official

Total

Less Discount (if applicable)

Sub Total

The Paperwork Reduction Act of 1995 requires us to notify you that this information collection is in accordance with the clearance requirements of section 3507 of the Paperwork Reduction Act of 1995. We may not conduct or sponsor, and you are not required to respond to, a collection of information unless it displays a valid OMB number. We anticipate that the time expended by all individuals who must complete this form will average 5 minutes. This includes the time it will take to read instructions, gather the necessary facts and fill out the form.

PRIVACY ACT INFORMATION: The information requested on this form is solicited under authority of Title 38, U.S.C., Veterans Benefits, and will be used to determine the cost effective company. Additional information may be solicited during the course of processing your application. The information you supply may also be disclosed outside the VA as permitted by law or as stated in the "Notices of Systems of VA Records" 24VA136, published in the Federal Register.

Disclosure is voluntary, however, failure to furnish the information will result in our inability to process your quotation promptly.

OMB Number: 2900-0188 Estimated Burden: 5 minutes

FL 10-90

10 - 10 S H

SEP 2008

V. A. FORM JULY 19 98

VA FORM

In Reply Refer To:

DEPARTMENT OF VETERANS AFFAIRS

This letter is submitted to secure an estimate for the information listed on the attached. It does not constitute a purchase order; nor is it to be considered as authority for delivery or work to be started. This letter authorizes you to contact the veteran listed on the attached for additional information and/or to schedule an appointment for evaluation. Based upon your assessment, you are required to provide us the most accurate estimate possible. Your estimate is expected within five (5) business days from the date of this letter unless you notify the VA Approving Official. Please fill out the attached and return via facsimile to the Department of Veterans Affairs facility indicated above. Consideration of the purchase of the item(s) listed in the attached will be made and, if approved, a purchase order will be prepared and forwarded to you. At that time, you are authorized to start work. You may retain one copy of this letter and the attached for your files. If you have any questions, please contact the VA Approving Official at the telephone number listed on the attached. Sincerely, Attachment: VA Form FL 10-90 SECTION I - (To be completed by requesting VA Facility) \\iaimain\apps1\Pam_Ward\Logos\Formlogo.jpg Department of Veterans Affairs

REQUEST TO SUBMIT QUOTATION

INSTRUCTIONS: Please fill out vendor estimate in Section II below and submit to the requesting VA facility.

VENDOR

REQUESTING VA FACILITY

VETERAN INFORMATION

An estimate for the above listed items(s) is requested. YOUR QUOTATION DOES NOT CONSTITUTE A PURCHASE ORDER NOR IS IT TO BE CONSIDERED AS AUTHORITY FOR DELIVERY OR WORK TO BE STARTED. This request authorizes you to contact the above named veteran for additional information and/or to schedule an appointment for evaluation. Upon completion of the estimate, return via facsimile to the Department of Veterans Affairs facility indicated above. Your estimated is expected within 5 business days from the date of the request unless you notify the VA Approving Official.

Consideration of the purchase of the above will be made, and, if approved, a purchase order will be prepared and forwarded to you. You may retain a copy of this request for your files.

SECTION II - VENDOR'S ESTIMATE (To be completed by Vendor) Estimate should be itemized, separating materials from labor costs HCPCS (if known) Item(s) or Service(s) Qty Unit Unit Cost Total Cost The Paperwork Reduction Act of 1995 requires us to notify you that this information collection is in accordance with the clearance requirements of section 3507 of the Paperwork Reduction Act of 1995. We may not conduct or sponsor, and you are not required to respond to, a collection of information unless it displays a valid OMB number. We anticipate that the time expended by all individuals who must complete this form will average 5 minutes. This includes the time it will take to read instructions, gather the necessary facts and fill out the form.

PRIVACY ACT INFORMATION: The information requested on this form is solicited under authority of Title 38, U.S.C., Veterans Benefits, and will be used to determine the cost effective company. Additional information may be solicited during the course of processing your application. The information you supply may also be disclosed outside the VA as permitted by law or as stated in the "Notices of Systems of VA Records" 24VA136, published in the Federal Register. Disclosure is voluntary, however, failure to furnish the information will result in our inability to process your quotation promptly.

OMB Number: 2900-0188 Estimated Burden: 5 minutes 8.0.1291.1.339988.308172