1165843_Signed_Nova_Flex_maintenance.pdf

Request for i-Procurement Entry

CDER OPQ

Completed by Purchaser:

Maintenance agreement-Nova BioProfile Flex with Autosampler

Contract # (if option year):

25235

Ver. 5, 4-8-14

Office/Division:

Title:

Total Transaction $ Amount: (digits only)

Object Class Code:

Option year (if exists)

$48,500.00

We require a maintenance agreement to perform preventative maintenance on our Nova Bioprofile flex and the associated autosampler and sampling boxes.

Justification:

Total contract price including 2 option years is $149,500 Preventative maintenance for 12 months including 4 PM visits a year and replacement of parts.

Description:

OBP/DBRR-II

COR / Requestor signature: Date: Apr 7, 2016

Office Director signature: Date:

Completed by Contracts Staff:

Date: Apr 11, 2016Contract's Team signature:

CIN

Required: X CIN not

Required:

AAP#/

CIN: CDER-16-C-1229

Funding Type (#5):

(if 2nd type)

Funding Type (#5):

(if 2nd type)

Funding Type (#5):

(if 2nd type)

Funding Type (#5):

(if 2nd type)

PDUFA

CAN#: (4th) (if needed)

CAN#: (3rd) (if needed)

CAN#: (2nd) (if needed)CAN#: (1st) 6PP9BRE

CAP Center Item Number: (when >= $150,000

Completed by Budget Staff / Officer:

AA

Cost Code:

Identification Number

Budget Officer signature: Date: Apr 11, 2016

Print Form Reset Form

Tagging Code: P81608AA0049ABC Tagging

Code:

Tagging Code:

Tagging Code:

Funding $ Amount:

(if 4th type)

Funding $ Amount:

(if 3rd type)

Funding $ Amount:

(if 2nd type)

Enter digits only for Funding amounts, no $ or commas:

Funding $ Amount: $48,500.00

Request for i-Procurement Entry

CDER OPQ

Completed by Purchaser:

Contract # (if option year):

Ver. 5, 4-8-14 Office/Division:

Title:

Item Description Item Description: (If contract, use title from Acquisition Just. form; no more than 6 words in length) Total Transaction $ Amount: (digits only) Object Class Code:

Option year (if exists) Justification:

Description:

Completed by Contracts Staff:

Completed by Budget Staff / Officer:

Cost Code:

Identification Number Enter digits only for Funding amounts, no $ or commas:

9.0.0.2.20120627.2.874785

Preventative maintenance for 12 months including 4 PM visits a year and replacement of parts.