PHCC Technology Committee
Technology Procurement Request Form

Requester's Name:
Requester's Email:
Requester's Phone:

Description of the Procurement: - A specific, but brief, description of the technology project or goods and services sought with this request.
This should include the purpose of the procurement or technology, such as Equipment Replacement or Software for Performance Monitoring, ETC.

Desired Implementation Date:

URL where a description can be found:

Procurement Type:

Estimated Total Cost: $

Projected Use Type:

Justification of the Procurement:

Additional Issues to be Considered: