This form is to be used to aid departmental staff in relating information necessary in the processing of emergency purchase.  Your cooperation in answering the questions listed below will assist the purchaser in handling the order expeditiously.  Please complete the form and forward to the Purchasing Department.  If more space is required, please attach additional pages.

1. State the reason for the emergency purchase by explaining what the emergency is and what caused the emergency situation.

2. State the facts supporting that the agency will suffer financial or operational damage or risk of damage if the needs or not satisfied immediately (Be specific).

3. State the reason why the needs were not or could not have been anticipated. 

4. State the reason and process used for selecting the vendor

5. Name and phone number of selected vendor

6. List any additional information that may aid the purchaser in processing this emergency purchase.

I certify that, to the best of my knowledge, the above information is true and accurate and that no other material fact or consideration offered or given has influenced this recommendation for an emergency purchase

 

Submitted By:

                        (printed name, title and department)

 

Signature:                                                                                                                             

 

 

Approved By:                                                                                                                      

                            (Purchasing Manager)                                                                                        Date

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