SRU Desks Intallation Service 55r.pdf

PDF 139 KB Posted Feb 6, 2025

Attached to: Supply Blanket Purchase Agreement (Hardware)
Solicitation number: W911S255U0321
Issued by: Department of the Army Materiel Command Mission and Installation Contracting Command Fort Drum

About this file

Written by GovTribe AI · Feb 6, 2025

This is a Request for Equipment (CEEP & Property Book Items) form template used by the Department of the Army at Fort Drum for requesting equipment, supplies, services and publications. The 3-page form (MCID-LO FM 55-R) includes sections for item description, source/vendor information, pricing, utilities requirements, installation details, and required approvals.

The final page shows a completed example request for a Bosch Desk Installation service from Better Direct (PO Box 7430, Tempe, AZ) for SRC124HCSU QTY 44, including expert assembly, optimal placement and clean-up. The request dated July 16, 2024 is for 1 unit at $17,000.00 with priority code 13, submitted by SRU division with POC Mr. Contreras and telephone (315) 772-2645. The DODDAC code is W81DJG. The form requires certification signatures from both the requisitioner and department chief to validate the mission requirement.

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MED MAINT IMD FACILITIES ENV CARE

REQUEST FOR EQUIPMENT(CEEP & PROPERTY BOOK ITEMS)

(06 Must be Justified)

DOCUMENT #

ITEM DESCRIPTION: (Include Manufacturer and Picture)

SOURCE/VENDOR PHONE:

SOURCE/VENDOR COMPLETE ADDRESS:

SOURCE/VENDOR:

FROM: (Division / Section) POC: HAND RECEIPT CODE:

SUBMIT TO:

PROPERTY BOOK OFFICE

BLDG # P11055

DATE: TELEPHONE # : APC FC:

ITEM REQUESTED

PART/STOCK # CATALOG #

GSA/VA SCHEDULE

UNIT PRICE:

QUANTITY:

TOTAL PRICE:

WEB PAGE ADDRESS (IF ANY):

PRIORITY:

NOTE: Attach Manufacture's Literature, Operating Instructions, and Maintenance Manuals (Attach 2 copies per item for medical equipment).

LIST OF ACCESSORIES / SUPPLIES: (Attach additional sheet if necessary) DO ITEMS NEED TO BE STOCKED BY LOG?

WHAT DOES THIS REPLACE? (Fill in only if Applicable)

NOMENCLATURE: NSN: ECN: SERIAL #: DATE IN SERVICE:

WHAT CONSUMABLE DOES LOG STOCK FOR REPLACED ITEM?

BUILDING #: ROOM #: WALL: NEXT TO:

(Be Specific)

WHAT MODIFICATIONS WILL BE NECESSARY? (Be Specific, i.e. Cabinets moved, etc.) Attach sheets if necessary, CEEP

UTILITIES REQUIRED FOR INSTALLATION

HOT WATER VOLTAGE

COLD WATER

WHO WILL TRAIN OPERATORS?

MECHANICAL

MORE VENTILATION/SPECIAL EXHAUST

IS EQUIPMENT PORTABLE? IS ASSEMBLE REQUIRED?

WHO WILL ASSEMBLE?

COST COST

JUSTIFICATION: Attach sheets if necessary, CEEP. (Include a Recent Quote from the Source/Vendor and Sole Source Justification if Applicable)

PBO SAFETY LOG PT SAFETY

MCID-LO FM 55-R, AUG 2007

I CERTIFY THAT THIS IS A VALID MISSION REQUIREMENT. I CERTIFY THAT THIS IS A VALID MISSION REQUIREMENT.

HAND RECEIPT HOLDER CHIEF, DEPARTMENT / DIVISION

NETWORK DROP PHONE LINES

WHERE WILL IT GO? (Fill in only if Applicable)

ELECTRICALPLUMBING

AUTHORIZATION

(Exact Location Necessary)

COMMUNICATION

AMPERAGE

# OF OUTLETS

DRAINS WATTS

PHASE

HERTZ

GAS

AIR

VACUUM

OTHER OTHER

LC v1.00

Record Name

Request for Equipment (CEEP & PROPERTY BOOK ITEMS)

SUBMIT TO:

PROPERTY BOOK OFFICE

BLDG #P11055

FROM: (Section) DATE: POC:

TELEPHONE #:

COMMENTS FROM ACTIVITIES:

MEDICAL MAINTENANCE:

NOMEN: MAINT SIG:

ID#: DEVICE #:

MFR: LE:

FACILITIES:

SAFETY:

IMD:

LOG:

MCID-LO FM 55-R, AUG 2007 Page 2 of 3

AI REQ:

YES NONOYES

REQUEST FOR SUPPLIES/SERVICES/DURABLE

FOR: FROM: (Division & Section) DATE:

TELEPHONE #

DODDAC

POC:

ITEM DESCRIPTION:

ADDRESS:

MANUFACTURER: PHONE #

APC CODE: CREDIT CARD:

Logistics Division Fort Drum, NY 13602-5004

JULIAN DATE:

SERVICE #

ITEM REQUESTED

NOTE: Attach Manufacturer's Literature

VERIFICATION / ACTION

REQUEST FOR BOOKS / PUBLICATIONS

VERIFICATION / ACTION

DATE:

REQUESTING

ACTIVITY:

TITLE OF BOOK:

POC: TELEPHONE:

APC:

EDITION:

DODDAC

YEAR

PART/STOCK # CATALOG # PAGE # GSA/VA SCHEDULE

PREVIOUS ORDER: UNIT PRICE:

QUANTITY REQUEST:

TOTAL PRICE:NOMENCLATURE:

PUBLISHER: ISBN #

TELEPHONE:

PRICE: QUANTITY: TOTAL:

TELEPHONE / FAX EQUIP TSO / APPROVED / DISAPPROVED

REQUISITIONER SIGNATURE: CHIEF, DEPARTMENT/BUDGET

WAS THIS BOOK PURCHASED IN THE PAST?

DOES THE COMPANY ACCEPT CREDIT CARDS?

WHEN?

ADP EQUIPMENT IMD / APPROVED / DISAPPROVED

CATALOG #:PRIORITY: (06 must be justified)

ADDRESS:

I CERTIFY THAT THIS IS A VALID MISSION REQUIREMENT.

REQUISITIONER SIGNATURE

I CERTIFY THAT THIS IS A VALID MISSION REQUIREMENT.

CHIEF, DEPARTMENT / BUDGET

MCID-LO FM 55-R, AUG 2007 Page 3 of 3

MCID-LO FM 55-R, AUG 2007

REQUEST FOR EQUIPMENT(CEEP & PROPERTY BOOK ITEMS)

DHA

MED MAINT IMD FACILITIES ENV CARE

REQUEST FOR EQUIPMENT(CEEP & PROPERTY BOOK ITEMS)

(06 Must be Justified)

DOCUMENT #

ITEM DESCRIPTION: (Include Manufacturer and Picture)

SOURCE/VENDOR PHONE:

SOURCE/VENDOR COMPLETE ADDRESS:

SOURCE/VENDOR:

FROM: (Division / Section)

POC:

HAND RECEIPT CODE:

SUBMIT TO:

PROPERTY BOOK OFFICE BLDG # P11055

DATE:

TELEPHONE # :

APC FC:

ITEM REQUESTED

PART/STOCK #

CATALOG #

GSA/VA SCHEDULE

UNIT PRICE:

QUANTITY:

TOTAL PRICE:

WEB PAGE ADDRESS (IF ANY):

PRIORITY:

NOTE: Attach Manufacture's Literature, Operating Instructions, and Maintenance Manuals (Attach 2 copies per item for medical equipment).

LIST OF ACCESSORIES / SUPPLIES: (Attach additional sheet if necessary)

DO ITEMS NEED TO BE STOCKED BY LOG?

WHAT DOES THIS REPLACE? (Fill in only if Applicable)

NOMENCLATURE:

NSN:

ECN:

SERIAL #:

DATE IN SERVICE:

WHAT CONSUMABLE DOES LOG STOCK FOR REPLACED ITEM?

BUILDING #:

ROOM #:

WALL:

NEXT TO: (Be Specific)

WHAT MODIFICATIONS WILL BE NECESSARY?

(Be Specific, i.e. Cabinets moved, etc.) Attach sheets if necessary, CEEP

UTILITIES REQUIRED FOR INSTALLATION

HOT WATER

VOLTAGE

COLD WATER

WHO WILL TRAIN OPERATORS?

MECHANICAL

MORE VENTILATION/SPECIAL EXHAUST

IS EQUIPMENT PORTABLE?

IS ASSEMBLE REQUIRED?

WHO WILL ASSEMBLE?

COST

JUSTIFICATION: Attach sheets if necessary, CEEP. (Include a Recent Quote from the Source/Vendor and Sole Source Justification if Applicable)

PBO SAFETY LOG PT SAFETY

MCID-LO FM 55-R, AUG 2007

I CERTIFY THAT THIS IS A VALID MISSION REQUIREMENT.

HAND RECEIPT HOLDER

CHIEF, DEPARTMENT / DIVISION

NETWORK DROP

PHONE LINES

WHERE WILL IT GO? (Fill in only if Applicable)

ELECTRICAL

PLUMBING

AUTHORIZATION

(Exact Location Necessary)

COMMUNICATION

AMPERAGE

# OF OUTLETS

DRAINS

WATTS

PHASE

HERTZ

GAS

AIR

VACUUM

OTHER

LC v1.00 Record Name Request for Equipment (CEEP & PROPERTY BOOK ITEMS)

SUBMIT TO:

PROPERTY BOOK OFFICE BLDG #P11055

FROM: (Section)

DATE:

POC:

TELEPHONE #:

COMMENTS FROM ACTIVITIES:

MEDICAL MAINTENANCE:

NOMEN: MAINT SIG:

ID#: DEVICE #:

MFR: LE:

FACILITIES:

SAFETY:

IMD:

LOG:

MCID-LO FM 55-R, AUG 2007

AI REQ:

LC v1.00

YES

REQUEST FOR SUPPLIES/SERVICES/DURABLE

FOR:

FROM: (Division & Section)

DATE:

TELEPHONE #

DODDAC

POC:

ITEM DESCRIPTION:

ADDRESS:

MANUFACTURER:

PHONE #

APC CODE:

CREDIT CARD:

Logistics Division Fort Drum, NY 13602-5004

JULIAN DATE:

SERVICE #

ITEM REQUESTED

NOTE: Attach Manufacturer's Literature

VERIFICATION / ACTION

REQUEST FOR BOOKS / PUBLICATIONS

VERIFICATION / ACTION

DATE:

REQUESTING

ACTIVITY:

TITLE OF BOOK:

POC:

TELEPHONE:

APC:

EDITION:

DODDAC

YEAR

PART/STOCK #

CATALOG #

PAGE #

GSA/VA SCHEDULE

PREVIOUS ORDER:

UNIT PRICE:

QUANTITY REQUEST:

TOTAL PRICE:

NOMENCLATURE:

PUBLISHER:

ISBN #

TELEPHONE:

PRICE:

QUANTITY:

TOTAL:

TELEPHONE / FAX EQUIP TSO / APPROVED / DISAPPROVED

REQUISITIONER SIGNATURE:

CHIEF, DEPARTMENT/BUDGET

WAS THIS BOOK PURCHASED IN THE PAST?

DOES THE COMPANY ACCEPT CREDIT CARDS?

WHEN?

ADP EQUIPMENT IMD / APPROVED / DISAPPROVED

CATALOG #:

PRIORITY: (06 must be justified)

ADDRESS:

I CERTIFY THAT THIS IS A VALID MISSION REQUIREMENT.

REQUISITIONER SIGNATURE

I CERTIFY THAT THIS IS A VALID MISSION REQUIREMENT.

CHIEF, DEPARTMENT / BUDGET

MCID-LO FM 55-R, AUG 2007

LC v1.00

date1:

dateinservice:

handreceiptcode1:

ducoment1:

poc1:

apcfc1:

itemdescription1:

sourcevendor1:

LABEL11: 0

sourceaddress1:

sourcephone1:

partstocknumber:

catalognumber:

unitpricepg1:

priority1:

quantity:

webpageaddress:

gsavaschedule:

listaccessories:

stockedlog:

nomenclaturepg1:

nsn:

ecn:

serialnumber1:

consumable:

nextto1:

buildingnumber:

roomnumber:

wall: 1

hotwater:

voltage:

ventilation:

coldwater:

amperage:

drains:

watts:

portable:

assembly:

gas:

phase:

air:

hertz:

trainoperators:

assembly2:

vacuum:

numberofoutlets:

otherplumbing:

otherelectric:

costtraining:

costassembly:

networkdrop:

phoneline:

from1:

telephone1:

Click to print form:

Click to return to catalog:

Click to save form:

Save As:

Click to route form:

Name of record:

FormAction: SaveReturn

intFormVerID: 8203

intViewID: 1

FormRecNo:

intStageID: 8185

SignatureField: AMED-Kim.Romig

strFormTable:

tmpRecNo:

FormFields:

fscSubmitURL: https://forms-conus.amedd.army.mil/fsgSCM/ffSubmitXFA.aspx?id=FE0C993A9B3C38A24B862D62B498674223900756CB998829CC29B1A2CDD41A7C871465EEEA734386EDF1770763665ED11029FCFF0830CFC620F03DB804F0C87F8D5F1EA2F7407DC8

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UserName: Romig, Kimberly S Mrs CIV USA MEDCOM GAHC

BtnNam:

maintsigyes2: 0

maintsigno: 0

aireq2: 0

aireqno: 0

datepage2:

from2:

telephonepage2:

nomen2:

idnumber:

device2:

mfr:

lepage2:

facilities:

safety:

imd:

log:

poc2:

date2pg3:

datepage3: 2024-07-16

juliandate: 2024-07-16

serviceno:

frompage3: SRU

telephonepage3: 3157722645

doddac: W81DJG

pocpage3: Mr. Contreras

apccodepage3:

LABEL56: 0.00000000

creditcardpage3:

itemdescriptionpg3: Bosch Desk Installation for SRC124HCSU QTY 44; Expert Assembly - Optimal Placement - Clean-Up.

manufacturerpg3: Better Direct

phonepg3: 4809213858

addresspg3: PO Box 7430 Spacer

Tempe, Arizona 85281-0015

partstockno: DESK INSTAL SV

catalogno:

pageno:

nomenclaturepg3:

priviousorder:

unitpricepg3: 17000.00

quantityrequest: 1

gsava:

priioritypg3: 13

catalogno2:

pocbooks:

pocphonebooks:

requestingactbook:

doddacbooks:

apcbooks:

titlebook:

yearbook:

editionbook:

publisherbook:

isbnbook:

addressbook:

telephonebook:

pricebook:

quantitybook:

bookpast:

whenpast:

acceptcreditcards:

NumericField1: 17000.00000000

File details come from the government source that posted it. Updated Feb 6, 2025.