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Requestor Name:Department Name:
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Submission Date:Description of Services:
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CompanyCompanyCompany
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Vendor Name:
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Sales Representative/Contact:
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Phone:
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Quote Date:
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Payment Terms (Net 30) Y / N:
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Purchasing Co-Operative
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Contract No.:
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Vendor Reference/Quote No.:
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Quote Expiration Date:
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*Hourly Rate: * Flat Rate:*Hourly Rate: * Flat Rate:*Hourly Rate: * Flat Rate:
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Total:
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 Recommended Provider (Ö):
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*Additional information for pricing may be attached to this form.
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Basis of Award (Check One):
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ÿ Lowest Price Proposal
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ÿ Best Value (Please provide Vendor selection justification below i.e. additional services, free delivery, etc.)
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Department Head/Principal Signature:
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SignatureDate
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Authorized Purchasing Agent Signature:
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SignatureDate
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NOTE: This form is required to compare pricing for federally funded requirements valued at $10K or MORE from a minimum of three "CoOp Vendors", if available, or “Non-CoOp Vendors” if no contract is available.
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