CONTRACT NUMBER: ______________
California State Polytechnic University, Pomona
Procurement Services
(REV 12/22/2021)
(Internal Use Only)
Page 1 of 2
CONTRACT REQUEST FORM
For use by California State Polytechnic University, Pomona Departments requesting the development or review and
signature of a Contract. This Form applies to all new and existing renewal Contract requests where State Funds are
not being encumbered. This form does not apply to Public Works construction and/or related contracts.
All information must be provided and all questions must be answered. Responses should be thorough or this request
may be returned for more information. Attach additional sheets and supporting documentation as necessary.
PART I: Requestor Information
Division/ College:
Department:
Name and Telephone No:
Email Address:
PART II: Contractor / Service Provider or Site Information
Contractor / Service Provider
or Site
Name & Address:
Contact Name :
Telephone Number:
Email Address:
PART III: Contract Information
Classification of Proposed Contract: (i.e. Clinical Agreement, Federal Work Study, International Study Abroad,
Internship Agreement, Lease Agreement, Internal Master Agreement, General “Zero Dollar” Agreement, Service
Learning Agreement, Student Teaching Agreement, Teaching Intern Agreement , EULA(s) or other)
NARRATIVE QUESTIONS:
1. Describe the reason for requesting this contract and the anticipated benefit to the University.
2. Provide an overview of the proposed scope of this contract.
3. Describe any other significant factor(s) that will assist in the review and approval of this request.
PART IV: Documentation
Provide the following documents as part of the request documentation with this Contract
Request F
1.
orm (REV 12/22/2021) :
1. Copy of the proposed contract and/or proposal.
2. Any additional back-up information that will assist in the processing of this Contract Request.
3. All Software related Agreements must be pre-approved by Campus IT - ATI Section 508
Compliance Documentation must be provided as part of this Request.
CONTRACT NUMBER: ______________
California State Polytechnic University, Pomona
Procurement Services
(REV 12/22/2021)
(Internal Use Only)
Page 2 of 2
PART V: Required Approvals
This form requires approval by the highest ranking department representative or designee, prior to submitting to
California State Polytechnic University, Pomona- Procurement Services. The typed name and signature must
match. The highest ranking Department Representative or designee may
designate one
person to
sign on his/her
behalf - Subject
to CPP- Procurement Services approval.
Name/Title (typed):
Signature:
Date:
PART VI: Procurement Services Review (Procurement Services Use Only)
Buyer Name:
Date Received:
Comments/Notes:
SUBMITTAL INSTRUCTIONS:
Return this completed Contract Request Form and all back-up documentation via email to:
QUESTIONS:
Questions regarding request process or the required forms should be directed to:
