HIGHER EDUCATION SYSTEM
WV-96 AGREEMENT ADDENDUM PROBLEM SUMMARY FORM
Institution
Contact Name Phone #
Address
Contract Information:
Purchase Order No:
Was the Contract bid?
Yes No
Was WV-96 part of the bid document?
Yes No
Was vendor lowest bid?
Yes No (If no, attach justification material)
Is this a sole-source contract? Yes No (If no, attach justification material)
If appropriate, summarize other bids on back of this form.
Please print or type.
Vendor Contact Information: (This person must have authority to negotiate and approve terms and conditions for the vendor.)
Vendor Name Phone#
Contact person & title Email
Address
Background Summary:
Contract Purpose & significance to institution/department:
Deadline for contract approval:
(Due to expiring funds, grant conditions, etc.)
Reason:
Vendor's stated objection(s) or desired changes (Attach appropriate documentation or relevant communications):
Possible alternatives or suggested solutions:
Email
Date
Notes:
1. Please attach a copy of the P.O. and contract documents with this form.
2. Send form and associated materials directly to Deputy Attorney General Dawn Warfield, Room E-26
State Capitol Building, Charleston, WV 25305 or by email to dawn.warfield@wvago.gov
WV-96 Problem Summary Form (2/10/10)
