Free revised SL Delegation Request.xls - Indiana

REQUEST FOR DELEGATION OF PURCHASING AUTHORITY
State Form 52083 (3-05) INDIANA DEPARTMENT OF ADMINISTRATION, PROCUREMENT DIVISION

Please provide the information requested below and submit this form to the IDOA Procurement Division. Name of Agency and Division/Facility Amount of Agency Delegation

Name of Agency Head

Business Unit Number

Name of Head Procurement Agent Email Address

Telephone number

NOMINATION OF A NEW PROCUREMENT AGENT Name of Nominated Procurement Agent Telephone Number Email Address Date of Training

Have you attended/are you scheduled for a Streamlining training session? Yes No

PLEASE LIST ALL CURRENT PROCUREMENT AGENTS WITH DELEGATION OF AUTHORITY IN YOUR AGENCY DIVISION OR FACILITY

Name

Phone Number

Email Address

Please attach an additional sheet if necessary.

DELEGATION OF AUTHORITY Based on the authority granted to agency named hereon, the undersigned hereby delegates to the procurement agent nominee the authority to procure printing and commodities not to exceed a single purchase limit equal to the agency purchasing delegation amount and to initiate the appropriate payment method as defined statute and policy. This delegation is not transferable, and shall expire upon resignation of the nominee. As deemed necessary by the Indiana Department of Administration, this authorization is subject to review and assessment and may be revoked at any time.

Approved: Signature of Nominated Procurement Agent Date (Month,day,year)

Signature of Agency Head Procurement Agent (ultimately responsible for agency purchasing)

Date (Month,day,year)

Signature of IDOA Training Coordinator

Date (Month,day,year)

Signature of IDOA Procurement Division Director or Designee

Date (Month, day,year)