DOA-3831STARPiggybackingRequest 435252-O775SECDOORHD-00.doc
DOC document 704 KB Posted
- Attached to
- Security Door Hardware
- Contract number
- 435252-O775SECDOORHD-00
- Issued by
- Wisconsin
About this file
This document is a Wisconsin State STAR Piggybacking Request form (DOA-3831) that allows state agencies to utilize existing contracts established by other agencies. The form involves the Wisconsin Department of Health Services (DHS) as the originating/contracting agency with business unit number 435, and references contract number 435252-O775SECDOORHD-00 with Toepfer Security Corporation (supplier ID 14267). The requesting agency information fields are left blank in this template form, which is administered by the Wisconsin Department of Administration's State Bureau of Procurement.
The contract covers security-related services under commodity/service codes 28536 and 68002, though the specific goods or services description is not detailed in this form. The document indicates this is an open, competitively bid contract, though the contract effective dates, renewal options, estimated annual spend amount, and request for bid/proposal number fields are not completed in this template version. The form includes provisions for software purchases that must comply with Wisconsin's STAR Software Purchasing Policy, and requires agencies to confirm that suppliers are not on ineligible vendor directories for tax collection or contract compliance issues.
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Other files
| File | Type | Posted |
|---|---|---|
| 435252-O775SECDOORHD-00.pdf | ||
| Awarded Bid Amounts 435252-O775SECDOORHD-00.pdf |
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Text version
State of Wisconsin
Department of Administration
DOA-3831 (r04/2018)
S. 16.71 Wis. Stats
State Bureau of Procurement
101 East Wilson Street, 6th Floor
P. O. Box 7867
Madison, WI 53707-7867
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: |
FORMCHECKBOX
My agency has notified the Originating/Contracting Agency identified in Section 2 below that we intend to use their contract and they have agreed.
Section 2: Originating/Contracting Agency
| Originating/Contracting Agency: |
| Agency Business Unit Number: |
| DHS |
| 435 |
| Originating/Contracting Agency Contact Name: |
| Phone Number: |
| E-Mail Address: |
Section 3: Contract Information
| Contract Number |
| Supplier Name |
| Supplier ID Number |
| 435252-O775SECDOORHD-00 |
| Toepfer Security Corporation |
| 14267 |
| Commodity/Service Codes: |
| 28536, 68002 |
| Estimated Annual Spend: |
| $ |
Is the purchase of software included in this request? If “yes”, complete Section 5 below. Yes FORMCHECKBOX No FORMCHECKBOX
N/A FORMCHECKBOX
Section 4: Eligibility Check
FORMCHECKBOX
My agency has validated the following, in compliance with the requirements of the State Procurement Manual, PRO-D-29.
FORMCHECKBOX
Contract is Open
| Contract Effective Dates: |
| Renewal Options: |
FORMCHECKBOX
Competitively Bid
| Request for Bid/Proposal Number: |
FORMCHECKBOX
Supplier(s) is/are not on the Certification for Collection of Sales and Use Tax Ineligible Vendor Directory
FORMCHECKBOX
Supplier(s) is/are not on the Contract Compliance Ineligible Vendor Directory
Impact, if any, on any minority business enterprise, disabled veteran-owned business or work center:
FORMCHECKBOX
Contract scope matches my agency’s need.
Description of the scope of the original procurement and how it corresponds to the commodity/service to be purchased:
State Bureau of Procurement Use Only
Request Approved:
FORMCHECKBOX
Yes FORMCHECKBOX No Date:
Approved By (Initial):
If UW, STAR Contract Number Assigned:
Section 5: Software Purchase Impact on STAR System
State agency software purchases must be compliant with the STAR Software Purchasing Policy (see PIM 17-001 and additional reference material attached therein). Please complete Section 5 for software purchases and include a technical contact that can be reached for questions related to your agency’s request.
Agency Technical Contact Name:
Phone Number:
E-Mail Address:
FORMCHECKBOX
My agency has reviewed the in-scope modules of the STAR System and we do not consider the requested software to overlap or conflict with system functionality.
FORMCHECKBOX
My agency has reviewed the in-scope modules of the STAR System and the requested software does appear to overlap or conflict, in whole or in part, with system functionality. We hereby request that approval be granted to make the purchase.
Provide a rationale for approval of the request where there appears to be a conflict or overlap with the STAR System:
This document can be made available in alternate formats to individuals with disabilities upon request.
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