CONTRACT INTAKE FORM End Date: ______ Contract 7ype

CONTRACT INTAKE FORM
Submit completed form, contract, and any related documents to [email protected]
CONTRACT DETAIL
No
Select Type
Contract 7ype: ________
__________________ Start Date: _________ End Date: _________ Renewal:____
Vendor Name: _____________________________________________ Contract Obligation: $_____________
Vendor Contact: ____________________________________ Phone: _____________ Fax: _____________
Vendor Email: _______________________________________________________
Contract Summary:
(Describe purpose in enough detail to facilitate review. For example, is the software program desktop or hosted website? What
information is exchanged? Where is it stored? Any special IT requirements? Etc.)
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
All necessary documents are attached to contract. (If contract refers to other documents
[i.e., Exhibit A, Privacy Policy, etc.], those documents must be submitted, as well.)
Requesting Department: ________________________ Contact Person: ___________________ Ext.:_______
AUTHORIZED ADMINISTRATOR CERTIFICATION (having budget authority)
Administrator’s Name: _______________________________________________________________________
I have reviewed this contract and am satisfied with its description of the goods and/or services to be
provided to the University. I also acknowledge and accept the University’s obligations as described
in the agreement.
I certify that neither I nor any department employee involved with the selection of the vendor or review
of the contract has a personal, family or business relationship with the vendor. (If there is a business or
family relationship, contact General Counsel at Ext. 3046 to discuss.)
Ethics bulletin: http://ethics.ohio.gov/education/factsheets/Bulletin_gifts_and_entertainment.pdf
Ethics Commission Information Sheet: http://ethics.ohio.gov/education/factsheets/InfoSheet3-StateContracts.pdf
Names of employees involved with selection of vendor and contract review:
__________________________________________________________________________________________
For questions or to check on the progress of your contract, please call Contracts Management at 351-3265.
PRINT
RESET
Rev. 10.21.14