S.f. Administrative Code Chapters 12b And 14b Waiver Request Form (Cmd-201)
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2CITY AND COUNTY OF SAN FRANCISCO
CONTRACT MONITORING DIVISION
S.F. ADMINISTRATIVE CODE CHAPTERS 12B and 14B
WAIVER REQUEST FORM
(CMD-201)
FOR CMD USE ONLY
Send completed waiver requests to:
Request Number:
or
CMD, 30 Van Ness Avenue, Suite 200, San Francisco, CA
94102
Section 1. Department Information
Department Head Signature: __________________________________________________
Name of Department: ________________________________________________________
Department Address: _______________________________________________________
Contact Person: ____________________________________________________________
Phone Number: ____________________
E-mail : _____________________________
Section 2. Contractor Information
Contractor Name: __________________________________________________________
Vendor No.: ___________________
Contractor Address: __________________________________________________________________________________________
Contact Person: _____________________________________
Contact Phone No.: ____________________________________
Section 3. Transaction Information
Date Waiver Request Submitted: _______________________
Type of Contract: ______________________________________
Contract Start Date: __________________
End Date: __________________
Dollar Amount of Contract: $ _________________
Section 4. Administrative Code Chapter to be Waived (please check all that apply)
_____ Chapter 12B
_____ Chapter 14B Note: Employment and LBE subcontracting requirements may still be in force even when a
14B waiver (type A or B) is granted.
Section 5. Waiver Type (Letter of Justification must be attached, see Check List on back of page.)
_____ A. Sole Source
_____ B. Emergency (pursuant to Administrative Code §6.60 or 21.15)
_____ C. Public Entity
_____ D. No Potential Contractors Comply
____________
(Required) Copy of waiver request sent to Board of Supervisors on:
_____ E. Government Bulk Purchasing Arrangement
____________
(Required) Copy of waiver request sent to Board of Supervisors on:
_____ F. Sham/Shell Entity
____________
(Required) Copy of waiver request sent to Board of Supervisors on:
_____ G. Subcontracting Goals
_____ H. Local Business Enterprise (LBE)
CMD/HRC ACTION
12B Waiver Granted: __________
14B Waiver Granted: __________
12B Waiver Denied:
__________
14B Waiver Denied:
__________
Reason for Action: ___________________________________________________________________________________________
___________________________________________________________________________________________________________
CMD Staff: ________________________________________________________________
Date: _________________________
CMD Director: ______________________________________________________________
Date: _________________________
HRC Director (12B Only): _____________________________________________________
Date: _________________________
.
CMD-201 (June 2014)
This form available at:
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