Fillable REQUEST FOR QUOTATIONS (Southern West Virginia Community and Technical College)

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REQUEST FOR QUOTATIONS (Southern West Virginia Community and Technical College)

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WV-43 (REV. 10/04)
Vendor
w
Address
w
Telephone Number
w ( )
To Be Delivered To:
Date Acct. No.
Return by ______________
on ___________________
Item Number Quantity Unit Price AmountDescription
Delivery Requirements
PLEASE NOTE DELIVERY REQUIREMENTS AND QUOTE
DEFINITE DELIERY IN NUMBER OF DAYS AFTER RECEIPT OF
ORDER.
QUOTATIONS TO BE BASED ON TERMS AND CONDITIONS
PRINTED HEREON.
F.O.B.
REQUEST FOR QUOTATIONS
THIS IS NOT AN ORDER
Req. No.
Delivery Date
Terms
FEIN
Vendor - Authorized Representative and Title (Please Print) Authorized Vendor Signature
HIPAA Business Associate Addendum - The West Virginia State Government HIPAA Business Associate Addendum (BAA), approved by the
Attorney General, and available online at the Purchasing Division’s web site (http://www.state.wv.us/admin/purchase/vrc/hipaa.htm) is
hereby made part of the agreement. Provided that, the Agency meets the definition of a Covered Entity (45 CFR §160.103) and will be disclosing
Protected Health Information (45 CFR §160.103) to the vendor.
TOTAL
$
Return to:
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REQUEST FOR QUOTATIONS (Southern West Virginia Community and Technical College)

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Completed 27 July 2020

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