FORM PC-104 (10-92) - North Carolina



|STATE OF NORTH CAROLINA |[pic] | |

|DEPARTMENT OF INFORMATION TECHNOLOGY | |IT PROCUREMENT COMPLAINT TO VENDOR FORM |

|STATEWIDE IT PROCUREMENT OFFICE | | |

|PO Box 17209 | |Date:       |

|RALEIGH, NC 27619-7209 | | |

|FROM |SUBJECT |

|      | |

|(Agency) |Purchase Order No.:       Dated:       |

|      |(Attach copy) |

|(Address) |For Commodity No.:       |

|      | |

|(City, State and Zip Code) |Commodity:       |

|            | |

|(By) (Title) |TERM CONTRACT NO.:       |

|Phone No.:       | |

| |BID/QUOTE NO.:       |

|TO (Vendor) | |

|      | |

|(Name) |TO VENDOR - PLEASE NOTE AND COMPLY |

|      | |

|(Address) |Reply to the agency and to the Statewide IT Procurement Office within 15 calendar|

|      |days. Failure to reply may result in your company being deleted from our |

|(City, State and Zip Code) |prospective bidder’s mailing lists; and/or your future proposals not being |

|Phone No.:       |considered or removal from a contract. |

FOR ACTION VENDOR RECORD ONLY

MAKE THE COMPLAINT SPECIFIC AND PROVIDE DETAILS

We have the following complaint:

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