PR_FOR_7025-01-528-9283_-_5895-01-621-5148_DTD_21MAY15.pdf

FOR OFFICIAL USE ONLYNESSS V 1.12

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DEPARTMENT OF HOMELAND SECURITY

PROCUREMENT

ROCESS REQUEST

APIDLY

PROCUREMENT REQUEST NO.

DATE RECEIVED

1. NAME, PHONE NUMBER, AND ROUTING SYMBOL OF PERSON TO CONTACT

2. ORIGINATING OFFICE DATA

4. ADDITIONAL INFORMATION (Suggested supply sources, security data, etc.)

2. TYPE OF REQUEST (Check one)

A. NEW REQUEST

B. CHANGE TO

C. MODIFICATIONS TO

CONTRACT OR

ORDER NO.

5. APPROVALS 6. CONSIGNEE AND DESTINATION

APPROVING OFFICIALS ROUTING

SYMBOL

DATE INTERNAL ROUTING

INITIALS ROUTING

SYMBOL

(A) (B) (C) (D)

(1) AUTHORIZED REQUISITIONER

(2) ACCOUNTING CERTIFICATION OFFICER

(3)

(4)

7. DATE(S) REQUIRED

8. GOVERNMENT FURNISHING PROPERTY

YES NO

(If "YES" see par. 8 of Instructions on page 2.)

9. DESCRIPTION OF ITEMS OR SERVICES

ITEM

NO.

(A)

ITEM OR SERVICE (Include Specifications and Special Instructions) (B)

QTY

(C)

UNIT

(D)

ESTIMATED COST

UNIT

(E)

AMOUNT

(F)

10. ACCOUNTING DATA

SYSTEMS DATA INFORMATION CHECK APPLICABLE QUARTER

A G E N C Y

D I S T

APPN

CODE

LIM

CODE

AFC

CODE

PROGRAM

ELEMENT

COST

CENTER

OBJECT

CLASS TYPE FY P. R. NO. SUFFIX

AMOUNT

1ST 2ND 3RD 4TH

TOTAL

READ INSTRUCTIONS ON PAGE 2 PAGE

SEE SCHEDULE

SEE SCHEDULE

SEE SCHEDULE

TERRY COLIN

PBPL SUPPLY BRANCH

2115405B4200DI069-0000

X

1275 DANNER DR

AURORA, OH 44202

TAMMY KUHN-330-562-7070

NETWORK TECHNOLOGIES INCORPORATED

TERRY, COLIN PBPL-SUP 05/21/15

2 / B / 501 / 2015 / 38 / 42 / 1 / 0 / 42 / 00 / DI / 52011 / 2648 $49,626.00

PBPL-SUPPEGGY, HAYNES

FORM DOT F 4200,1,2CG (Rev. 2-94)

PREVIOUS EDITIONS ARE OBSOLETE

A L I

C

$49,626.00

2115405B4200DI069-0000

X

EMERGENCY

YES NO

X

X

070201520150610000 TAS:

TLColin Typewritten Text

MULTI LINE

PURCHASE

5895-01-621-5148 7025-01-599-9283

9. DESCRIPTION OF ITEMS OR SERVICES

ITEM

NO.

(A)

ITEM OR SERVICE (Include Specifications and Special Instructions) (B)

QTY

(C)

UNIT

(D)

ESTIMATED COST

UNIT

(E)

AMOUNT

(F)

DEPARTMENT OF HOMELAND SECURITY

PROCUREMENT REQUEST - CONTINUATION SHEET

PROCUREMENT REQUEST NO.

FORM DOT F 4200.1.2CG (Rev. 2-94)

2115405B4200DI069-0000

EA

EA

$ 2,034.00

$ 2,304.00

$ 42,714.00

$ 6,912.00

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5895 01-621-5148

RACKMUX-VS17-T-4USB

EACH UNIT TO HAVE ELECTROSTATIC PROTECTION IAW

TYPE III,

CLASS I OF MIL-B-81705E

W_AMENDMENT 1 DTD 02/08/2010.

EACH ITEM TO BE INDIVIDUALLY PACKAGED IAW THE

FOLLOWING:

MIL-STD-2073-1E W/CHANGE 17, METHOD 10

ASTM-D-3951-10

SFLC SP-PP&M-001 DTD 06/06/11

EACH ITEM TO BE INDIVIDUALLY MARKED IAW THE

FOLLOWING:

MIL-STD-129P W/CHANGE 4

SFLC SP-PP&M-001 DTD 06/06/11

BAR CODING REQUIRED, IF CAPABLE, TO COMPLY WITH

THE

FOLLOWING:

SFLC SP-PP&M-001 DTD 06/06/11

MFG NAME: NETWORK TECHNOLOGIES INC.

PART_NBR: RACKMUX-VS17-T-4USB

7025 01-599-9283

TERMINAL, DATA PROCESSING

EACH UNIT TO HAVE ELECTROSTATIC PROTECTION IAW

TYPE III,

CLASS I OF MIL-B-81705E

W_AMENDMENT 1 DTD 02/08/2010.

EACH ITEM TO BE INDIVIDUALLY PACKAGED IAW THE

FOLLOWING:

MIL-STD-2073-1E W/CHANGE 17, METHOD 10

ASTM-D-3951-10

SFLC SP-PP&M-001 DTD 06/06/11

EACH ITEM TO BE INDIVIDUALLY MARKED IAW THE

FOLLOWING:

MIL-STD-129P W/CHANGE 4

SFLC SP-PP&M-001 DTD 06/06/11

BAR CODING REQUIRED, IF CAPABLE, TO COMPLY WITH

THE

FOLLOWING:

SFLC SP-PP&M-001 DTD 06/06/11

MFG NAME: NETWORK TECHNOLOGIES INC.

PART_NBR: RACKMUX-VS17-NT-4USB

CONSIGNEE AND DESTINATION

2115405B4200DI069-0000

UNITED STATES COAST GUARD (SFLC)

SURFACE FORCES LOGISTICS CTR

08/21/15

08/21/15

RECEIVING ROOM - BLDG. 88

UNITED STATES COAST GUARD (SFLC)

2401 HAWKINS POINT ROAD

RECEIVING ROOM - BLDG. 88

BALTIMORE, MD 21226

2401 HAWKINS POINT ROAD

BALTIMORE, MD 21226

PROCUREMENT REQUEST NO. :

LINE NO. DESTINATION QTY DMR

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ACCOUNTING CERTIFICATION OFFICER

2115405B4200DI069-0000PROCUREMENT REQUEST NO. :

NAME ROUTING SYMBOL DATE

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PBPL-SUPPMICHAEL, TIBBS