Peralta Community College District 333 East 8th Street Oakland, California 94606 (510) 466-7225 For District Use Only FORM NO: Date Rec’d: INSTRUCTIONAL FURNITURE & EQUIPMENT PROCUREMENT REQUEST FORM (MEASURE A PROCUREMENTS ONLY) This form is to be use to request Measure A funding support for: * Program development, * Special instructional projects, and * Related furniture and equipment INCOMPLETE SUBMITTALS WILL BE RETURNED INSTRUCTIONS: 1 REQUESTOR to Complete SECTIONS I AND II REQUESTOR to obtain required signatures and approvals prior to submittal to District REQUESTOR to initiate a requisition, to be included as backup REQUESTOR to forward completed ORIGINAL Measure A Procurement Form and copy of requisition and any other pertinent backup documentation to: Atheria Smith, Acting Vice Chancellor, General Services Peralta Community College District Office Purchasing Department Tel: (510) 466-7225 Fax: (510) 587-7873 Email: gdowen@peralta.edu DISTRICT to logged and assign an internal tracking number (MAF#) Forms will then be forwarded to Finance and the Chancellor’s Office for signatures DISTRICT TO COMPLETE SECTION III (FINANCE) DISTRICT to send approved forms to Requestor Please remember to include the Measure A tracking number (MAF#) in the body of the requisition 8 file DISTRICT will keep the ORIGINAL Measure A Procurements Forms on Peralta Community College District Instructional Furniture & Equipment Procurement Request Form (MEASURE A ONLY) Updated: February 23, 2021 Page INSTRUCTIONAL PROCUREMENT REQUEST FORM (Measure A Procurement Only) SECTION I - PROCUREMENT BACKGROUND Date: Requeste r Phone: Location: Laney Department : COA Merritt Buildin g: Requested Funding Amount: Project Name: Berkeley City College Which best describes this procurement? Furniture / Equipment CRITERIA (Please check applicable box(es) ADA = ADA Compliance AVE = Audio visual equipment CHS = Computer hardware and software FUR = Furniture LIB = Library materials OIE = Other instructional and support equipment Programming - Proposed procurement not related to other college proposals or planned work Programming – Proposed procurement related to other college proposals or planned work Other: Will this be a one-time expenditure? Peralta Community College District Instructional Furniture & Equipment Procurement Request Form (MEASURE A ONLY) Updated: February 23, 2021 Yes No Page If No, how will this procurement be incorporated as an on-going expenditure into the department, program, curriculum and budget? Procurement description: (You may attach additional information.) Procurement justification: (Note: Procurement request must refer to Bond language.) What are the procurement objectives and benefits to the students, program, and college? Procurement estimates: (Please names and list the final cost estimates from three different vendors, suppliers, or trades In addition, please attach the original estimates.) Name Cost Appendix Description: (Please list any additional attachments, such as price quotes, etc.) Peralta Community College District Instructional Furniture & Equipment Procurement Request Form (MEASURE A ONLY) Updated: February 23, 2021 Page Peralta Community College District Instructional Furniture & Equipment Procurement Request Form (MEASURE A ONLY) Updated: February 23, 2021 Page SECTION II - CONTACT INFORMATION & CAMPUS APPROVALS COLLEGE CONTACT INFORMATION Contact: Email: Phone: COLLEGE APPROVALS OFFICE OF INSTRUCTIONAL SERVICES Vice President of Instructional Services: (Print Name) Signature: Email: Date: Phone: BUSINESS OFFICE ACCOUNT CODES: L FUND COST CENTER OBJECT PR ACTIVITY SPJ LN Will this impact any future budgets? No Yes Requisition No.: College Business Officer (Required for District Review): (Print Name) Signature: Email: Date: Phone: COLLEGE PRESIDENT’S OFFICE College President (Required for District Review): (Print Name) Signature: Email: Date: Phone: Peralta Community College District Instructional Furniture & Equipment Procurement Request Form (MEASURE A ONLY) Updated: February 23, 2021 Page SECTION III – DISTRICT APPROVALS (TO BE COMPLETED BY DISTRICT OFFICE Procurement: Budget Expenditure: MEASURE A RECOMMENDATIONS Approved Request Incomplete (Please complete highlighted areas) Return by: Rejected (Review justification below) APPROVALS GENERAL SERVICES _ Atheria Smith, Acting Vice Chancellor, General Services FINANCE Adhil Ahmed, Acting Vice Chancellor of Finance & Administration _ Date Date CHANCELLOR _ Dr Carla Walter, Acting Chancellor Peralta Community College District Instructional Furniture & Equipment Procurement Request Form (MEASURE A ONLY) Updated: February 23, 2021 Date Page