Tennessee Board Of Regents Contract Summary Sheet
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1Date Received by TBR: ____________________
Contract Number: _________________
(TBR internal use only)
TENNESSEE BOARD OF REGENTS
CONTRACT SUMMARY SHEET
If contract is submitted less than two (2) weeks before the effective date (1 month required for complex contracts), provide
an explanation of the delayed submission:
1.
Institution/Central Office: ________________________________________________ Phone: ____________________
Direct Contract Questions to: __________________ Fax: _______________________ Email: ____________________
2.
Contract with: ________________________ Address: _____________________________________________________
Contact Person: _______________________ Phone: _________________
3.
Purpose of Contract (include type – i.e. Dual Service, Clinical, etc.):
4.
This contract is (check all that apply):
Drafted by TBR (School)/not Standard Form
Software License Agreement
TBR Standard Form Agreement
Vendor Generated Contract
Renewal of an Existing Contract
Vendor Contract with Amendment
Modification of Existing or Form Contract
Contract includes Confidential Research Agreement
COPY OF AGREEMENT BEING AMENDED, EXTENDED OR PREVIOUS CONTRACT ATTACHED FOR REFERENCE AS
WELL AS ANY EXHIBITS.
5.
Contract Terms:
Term (i.e. 7/1/05 – 6/30/06, 1 year from execution, etc.): __________________________________________________
Possible Number of Renewals: __________
Lease:
yes
no
Payment Frequency: __________ Amount per Year: ____________Total Amount (w/possible renewals): _____________
6.
If this contract is a result of an RFQ/RFP, is the contract available for system-wide use:
yes
no
7. Check one:
Competitive Process
Non-Competitive Process*
* If competitive process is not used, attach supporting documentation, including the non-competitive justification form
8.
Non-Debarment Verification ( ):
Date Verified: _____________ 9. Ethnicity Code:
Select One
10. Contract Monitor (individual responsible for ensuring receipt of goods/services): ____________________________________
Frequency of monitoring (monthly, quarterly, semi-annually or annually): __________________________________________
Signature of Institution/Central Office official certifying that he/she has read this Contract and
recommends its approval.
____________________________________________
Signature (Department)
Signature of Institution/Central Office official certifying compliance with TBR Purchasing Procedures:
____________________________________________
Signature (Purchasing/Contracts Officer)
Form Completed by: _________________________________ Date: ______________________
(TBR 7/06)
Clear Form
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