Madhya Pradesh Public Health Services Corporation Limited
(MPPHSCL)
Procurement Indent
Indent No.:......
Dated: ......
Name of the Indenting Department:
Sr.No. / Description / Remarks
1 / Item Description in brief / ......
[Item type such as drugs, surgical, sutures, consumables, Implants, hospital equipment, hospital furniture, Office equipment, etc.]
2 / Name / List of Items to be procured / S.No / Name Of Item / Unit / Indicative Quantity / Estimated Unit Cost / Total Estimated Cost
Total
1. Please indicate expected % variation in indicative quantity mentioned in the table above %.
[In case of multiple items, please enclose separate sheet in the above format]
3 / Availability of Budget
(to the extent of Estimated
Cost at as Sr.No.2 above). / Budget sanctioned: Yes/No
[In case, budget is yet to be sanctioned, please confirm availability of budget up to date of award of contract also mention item is planned]
4 / Detailed Technical
Specifications of the items / [please attached detailed technical specifications of the items
to be procure, duly signed by indenting authority. The specifications should be generic in nature not vender specific.]
5 / Type of Procurement / One time Procurement: Yes/No
Annual Rate Contract: Yes/No
Proprietary Item Yes/No
(undertaking required)
(Justification)
Emergency: Yes/No
(Justification)
[Please tick as appropriate]
In case of proprietary item, please provide full contact details of source of the item and also give an undertaking that the indent item can only be procured form the named source and is not available or manufactured by any other source.
6 / Consignee location(s) / [please mention and attach complete details of consignee, including its address, name of contact person, contact details]
7 / Delivery Schedule required
(in case of one time procurement) / [Please indicate when the indented items are required to be delivered. In case it is not feasible to consider required delivery schedule, the Corporation may suitable modify in consultation with Indenting authority]
8 / Payment Schedule
(Suggested) / [Please indicate suggested payment Schedule. In case suggested payment schedule is not in line with prevailing business standards and practices, the Corporation may suitable modify in consultation with Indenting authority]
9 / Name / Title of Ordering
authority / ......
[Please mention name of authority, entitled to place purchase orders along with contact details]
10 / Name of Paying authority / ......
[Please mention name of authority who is authorized to release payment (only if, he/she is different than Ordering Authority]
11 / In case of Equipments
weather Guarantee/ warrantee/AMC/CMC is required? / {please specify equipment wise}
12 / In case of equipments whether the space is available for installation / {please specify the availability of space or in case it will be made available then approximate duration}
13 / Due to Sr.No.11 and 12
above the approximate cost of the equipment will rise? / {Yes/No, if yes then please specify}
14 / Qualification Criteria / {suppliers of Items for which indent have been raised are required to have any special certification/license if yes then please specify } Such as .....
15 / Blacklisting details / {For the Items mentioned in the indent form weather any supplier/manufacturer/dealer etc has been blacklisted if yes then please details of the supplier and duration of the blacklisting}
16 / Pre-qualification criteria / {Is there a need of calling samples for the items mentioned in the indent form as a part of technical evaluation/ prequalification criteria – Yes /No }
17 / Evaluation / {Please provide name’s and details of technical experts for technical evaluation / Pre-qualification }
18 / Quality Assurance / {Please give name and details of quality assurance person who will verify the supplied items at the time of delivery}
19 / Name(s) and contact details of nominated technical expert who may be contacted for any clarification regarding technical specifications / Sr. No. / Name / Designation / Mobile No. and E- Mail ID
[It is expected that the technical specifications provided are appropriately detailed, generic and has incorporated the quality requirements. However, before initiating procurement, the Corporation, may review suggest some changes in the technical specifications to make it generic, add value and suitable to invite competitive bidding. The technical expert so nominated shall be requested to review and approve such changes. The nominated technical expert may also be required to attend pre-bid meeting (if held) and meeting of Technical / Tender evaluation committee]
20 / Any other Information
21 / Declaration / We hereby promise to the Corporation that we will pay Service Charges of the MPPHSCL on Procurement of indented goods/services.
Name and signature of Indenting Authority (with date)
Note: - Please do not leave any column blank, if not applicable then please write Not Applicable (NA). If the details in the indent form are incomplete then Madhya Pradesh Pubic Health Services Corporation Limited (MPPHSCL) will not be responsible for the delay in procurement process.