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ContractorNendor: <br />Purpose: <br /> ~ount: <br /> <br /> ORIGINATING DEPARTMENT <br />(THIS IS THE ONLY SECTION TO BE COMPLETED BY ORIGINATING DEPARTMENT) <br /> Vendor Number: <br /> <br /> Account # budgeted: <br /> <br />Department Number: Dept. Rep. <br />TYPE OF CONTRACT: (Please Check One) I--~New ['-~Renewal Effective Date: <br /> Expiration Date: <br /> <br />[--] County Policy Review <br /> <br />['-] Workers Comp Insurance <br />[] Automobile Liability Insurance <br /> <br />.Original/copies to Vendor <br />,Copies to originating Department <br /> <br />Checklist <br /> <br />[--~ Vendor W-9 <br /> <br />General Liability Insurance <br /> <br />Distributed Copies. <br /> F-~ Other Routing Instructions <br /> <br />Department Head Signature: <br /> <br /> ,ature above verifies this document has been reviewed and a <br /> vllSCELLANEOUS NOTES: <br /> <br />Date: <br /> <br /> ~rtment Head. <br /> <br /> INFORMATION TECHNOLOGY DIRECTOR <br /> (Applicable only for hardware/software purchase or related services) <br />l'his document has been reviewed and approved by the Information Systems Director as to technical content. <br /> <br />IT Director's Signature: <br /> <br />Date: <br /> <br /> REQUIRED APPROVALS <br />Does this contract require Board of Commissioner action? Yes [] <br /> <br />Does this contract require County Manager action? <br /> <br />Yes [-~ <br /> <br />No [] Date of action: <br />No E~] Date of action: <br /> <br />Date Received: <br /> <br />CONTRACT ADMINISTRATOR <br /> ~ Contract Control #: <br /> <br />Sufficient funds are available in the proper account to pay for this expenditure. <br />A budget amendment is necessary before this agreement is approved. <br />A budget amendment is attached as required for approval of this agreement. <br /> <br />Yes r-] No <br />Yes [] No <br />Yes E~ No <br /> <br />~ Pre-audit certification completed. <br />Contract Administrator's Signature: <br /> <br />Date: <br /> <br />Additional Notes: <br /> <br /> <br />