PURCHASE INDENT FORM (GOODS)

All India Institute of Medical Sciences, Bhubaneswar.

Indent No: Date:

(To be Filled By Purchase Section.)

Details of Indenter/ Indenting Department

Name of Indenter: Dr.Debananda Sahoo Designation: Department:
Email ID: [email protected] Contact No: Name of HOD.

Requirement: (Please tick  )

Fresh Additional Repair/replacement Recurrent Any other (Specify)
EXISTING RC: YES/NO

CATEGORY OF ITEMS
Category Pack size/Unit Estimated Cost.
A. Consumables of (Including GST
a. Drugs measurement. etc)
b. Chemical &
Reagents Approx. Approx.
(Attach separate sheet. Unit Total cost
c. Disposable & Annex.1)
Consumables price
d. Office Stationary )
e. Sanitary
f. Repair
g. Any other (Please
Specify)
B. Assets (Non- Category IAC Approval Yes No
IT)
a. Equipment (Attach separate sheet. Annex.2.) Estimated Cost.
b. Instrument Note: 1. For high-end equipment (Including GST, Warranty, CMC/AMC etc.
c. Electrical items 5yr warranty followed by 5yr CMC
d. Electronic items is desirable. Approx. Unit price including Approx.
e. Accessories 2. For Medical equipment costing GST Total cost
f. Furniture more than 30 Lakhs, Specification
g. Replacement need to be vetted by External 3000.00 3000.00
h. Any other Experts.

C. Assets (IT) Category Estimated Cost.

(Attach separate sheet. Annex.2.A) (Including GST, Warranty, CMC/AMC etc
a. Computers.
b. Printers. (In case of IT Items the Approx. Unit price Approx.
c. Computer Departments will fill the Total cost
Accessories. ANNEXURE 2 A only, The IT Section
d. Network devices will raise an Indent to S&P after
e. Network examination of the same)
accessories
f. Software
g. Any other (Please
specify)

Yes NO
GeM Avaiability: Attach signed copy of suitable Attach signed copy of search result, with reasons
product leaflet from GeM and justifications.
GeM ARPTS to be signed by indenter
Availability at central store YES/NO Signature of Store Keeper Signature of ASO

Tentative desired delivery period and reasons.

If research Project. The Duration and Name of
the Project and PI, Project ID
Mode of procurement suggested GeM.149 I, II,III/ E Tender/Limited Tender/ R.C./ GFR 154/GFR 155/GFR 166 I , III (PAC)*,
166 II Emergency*.
*PAC/Emergency format to be attached.
N.B: Only typed indent without any cutting/over writing will be accepted. No specific Make/Brand to be mentioned other
than PAC items.

Signature & Seal of Indenting officer Signature & Seal of HOD.

 PURCHASE INDENT FORM (GOODS)
All India Institute of Medical Sciences, Bhubaneswar.

ANNEXURE-1
(CONSUMABLES)
(Drugs, Chemical & Reagents, Disposable & Consumables, Office Stationary, Sanitary, Repair, any other (Please Specify)
Category: Consumable Item:1. HBED PSMA 2. DOTA NOC

1. Pack size Total

Quantity (Packs) 1. HBED PSMA 20 PCS
2. DOTA NOC 20 PCS

2. Composition/formulae/Specification 1 YEARS
and Desired self-life.

3. Available stock in hand. NIL

Duration to last. NA

4. Indented item duration to last. 4 months

5. Last 6month to 1year consumption Attached

pattern
a. If chemical/reagents: Per
pack or per kit test done to
be mentioned.
(Attach separate sheet if
required)
6. Detail Purpose & Justifications. For PET-CT Scan470

7. Last purchase details. 1.350/24-25 dt 25.09.2024

P.O Number/Quantity/Per Unit (Attached)
Price.
8. Estimated cost is based on Total Amount Including GST = 4,70,400.00
Budgetary quotations, LPR, or Any
other.
9. Details of Distribution details if ONE TIME
applicable. (Attach Separate sheet if
required)
10. Details of Prospective Vendors/ RC- M/s B.J Madan & CO
OEM etc, (If in RC, mention the Space no 2,C-110/2nd Floor Naraina industrial Area
details) Any other remarks Phase -1 New Delhi 1100028

Signature & Seal of Indenting officer Signature & Seal of HOD.

 PURCHASE INDENT FORM (GOODS)
All India Institute of Medical Sciences, Bhubaneswar.

ANNEXURE-2
(ASSETS)
(Equipment, Instrument, Electrical items, Electronic items, Accessories, Furniture, Replacement, Any other)

Category: ACCESSORIES Item: SINGLE LIMB VALVE ADAPTER FOR TRANS PORT VENTILATOR(RESMED)
1. 1 PCS
Quantity

2. Detailed Specification
(Attach Separate Sheet if Required)
3. Details about the life of equipment-
/instruments etc.
4. Warranty in years.
As per requirement
CMC in years.
As per requirement
4. a. Last Procurement Details.
(P.O Number/Quantity/Unit Price)

b. Number of Same/similar items

presently in use
5. Detail Purpose & Justifications.
(Attach separate sheet if required)

6. Budgetary quotations.
(Including CMC, Warranty,
accessories/attachments etc)
7. Details of annual requirement of
consumable, accessories, spares
and cost thereof, if any.
8. Site readiness like area, power, civil
works etc.
9. Requirement of installation/training
(Operational/maintenance) etc
10. Details of Prospective Vendors/
OEM etc.
(Preferably three)
Any other remarks

Signature & Seal of Indenting officer Signature & Seal of HOD.

 PURCHASE INDENT FORM (GOODS)
All India Institute of Medical Sciences, Bhubaneswar.

TO BE SUBMITTED TO IT CELL
ANNEXURE-2 A
(ASSETS IT)
(Computers, Printers, Computer Accessories, Network devices, Network accessories, Software, Any other Please specify)
Category:…………………………………………….Item:…………………………………………………
1.
Quantity

2. Detailed Specification
(Attach Separate Sheet if Required)
(IT Section to examine the same &
Suggest)
3. Details about the life of indented
item. (IT Section to examine the
same & Suggest)
4. Warranty in years.
As per requirement
CMC in years.
As per requirement
4. a. Last Procurement Details.
(P.O Number/Quantity/Unit Price)

b. Number of Same/similar items

presently in use
5. Detail Purpose & Justifications.
(Attach separate sheet if required)

6. Budgetary quotations.
(Including CMC, Warranty,
accessories/attachments etc)
7. Details of annual requirement of
consumable if any.

8. Site readiness like area, power, civil

works etc.
9. Requirement of installation/training
(Operational/maintenance)
etc
10. Details of Prospective Vendors/
OEM etc.
(Preferably three)
Any other remarks

Signature & Seal of Indenting officer Signature & Seal of HOD.