"Emergency Purchase Request Form" - Mississippi

Emergency Purchase Request Form is a legal document that was released by the Mississippi Department of Information Technology Services - a government authority operating within Mississippi.

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Download "Emergency Purchase Request Form" - Mississippi

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3771 Eastwood Drive
Jackson, Mississippi 39211
Phone 601-432-8000 Fax 601-713-6380
Emergency Purchase Request
Project Title:
Stimulus (ARRA) Funds? Yes__ No __
Customer Contact Information
Agency/Public University:
Contact Person:
Address:
Phone:
Fax:
Email Address:
MAGIC Customer Number (only required from state agencies)
Division/Dept:
Handmail:
Yes
No
Project Summary
Narrative Description of Project
ITS Acquisition Approval (CP-1) should be effective through this date:
(Please allow time for all vendor invoices to be paid)
Cost Estimate or Actual Amount:
NOTE: The total purchases made shall only be for the purpose of meeting the needs created by the emergency situation.
Discuss Funding (e.g. how much of needed funding is definite; total project budget; any matching or other non state funds; fund number)
Acquisition Details
Items Requested:
Name
Quantity
Description
Building Location(s)
Emergency Purchase
► If applicable, attach a certified copy of the appropriate minutes of the agency’s board meeting regarding the emergency purchase
In compliance with Section 31-7-13 (j) of Mississippi Code, provide the following information as soon as possible following the emergency
purchase:
Does the situation fall under the definition of an emergency set forth in Section 31-7-1 (f) of the Mississippi Code?
What happened to cause the emergency?
Does this emergency threaten the health or safety of any person, or the preservation or protection of property? If so, proceed with the
emergency purchase and submit this paperwork to ITS after the fact. If not, complete and submit this paperwork to ITS for approval prior to
making purchases.
What would be the negative consequences of following normal purchasing procedures?
Basis for selection of vendor(s) to be used:
Vendor’s proposal attached:
Yes
No
Remit To
Vendor Name:
Vendor Address:
By my signature, I certify that, to the best of my professional knowledge the purchase of the requested products or services is an emergency as outlined in
the ITS Procurement Handbook, Rule 207.6:013-060 Procurement Types: Emergency Purchases, and as outlined in Mississippi Code annotated Section
31-7-13 (j). In addition, I acknowledge that there is a charge for ITS procurement services associated with this request which will be billed to the
requestor by ITS and that my agency/public university is responsible for these charges/costs.
_______________________________________________
________________________________________
Name (Agency Head or Public University President) / Title
Signature
Date
3771 Eastwood Drive
Jackson, Mississippi 39211
Phone 601-432-8000 Fax 601-713-6380
Emergency Purchase Request
Project Title:
Stimulus (ARRA) Funds? Yes__ No __
Customer Contact Information
Agency/Public University:
Contact Person:
Address:
Phone:
Fax:
Email Address:
MAGIC Customer Number (only required from state agencies)
Division/Dept:
Handmail:
Yes
No
Project Summary
Narrative Description of Project
ITS Acquisition Approval (CP-1) should be effective through this date:
(Please allow time for all vendor invoices to be paid)
Cost Estimate or Actual Amount:
NOTE: The total purchases made shall only be for the purpose of meeting the needs created by the emergency situation.
Discuss Funding (e.g. how much of needed funding is definite; total project budget; any matching or other non state funds; fund number)
Acquisition Details
Items Requested:
Name
Quantity
Description
Building Location(s)
Emergency Purchase
► If applicable, attach a certified copy of the appropriate minutes of the agency’s board meeting regarding the emergency purchase
In compliance with Section 31-7-13 (j) of Mississippi Code, provide the following information as soon as possible following the emergency
purchase:
Does the situation fall under the definition of an emergency set forth in Section 31-7-1 (f) of the Mississippi Code?
What happened to cause the emergency?
Does this emergency threaten the health or safety of any person, or the preservation or protection of property? If so, proceed with the
emergency purchase and submit this paperwork to ITS after the fact. If not, complete and submit this paperwork to ITS for approval prior to
making purchases.
What would be the negative consequences of following normal purchasing procedures?
Basis for selection of vendor(s) to be used:
Vendor’s proposal attached:
Yes
No
Remit To
Vendor Name:
Vendor Address:
By my signature, I certify that, to the best of my professional knowledge the purchase of the requested products or services is an emergency as outlined in
the ITS Procurement Handbook, Rule 207.6:013-060 Procurement Types: Emergency Purchases, and as outlined in Mississippi Code annotated Section
31-7-13 (j). In addition, I acknowledge that there is a charge for ITS procurement services associated with this request which will be billed to the
requestor by ITS and that my agency/public university is responsible for these charges/costs.
_______________________________________________
________________________________________
Name (Agency Head or Public University President) / Title
Signature
Date