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ContractorNendor: <br />Purpose: <br />Amount: <br />Department Number: <br /> <br /> ORIGINATING DEPARTMENT <br />(THIS IS THE ONLY SECTION TO BE COMPL~=.,t=D BY ORIGINATING DEPARTMENT) <br /> Vendor Number: <br /> <br /> Account # budgeted: <br />Dept. Rep. <br /> <br />TYPE OF CONTRACT: (Please Check One) I---INew I-]Renewal Effective Date: <br /> Expiration Date: <br />This document has been reviewed and approved by the Department Head as to technical content. <br /> <br />[] County Policy Review <br /> <br /> [] Original/copies to Vendor <br /> []. <br /> <br /> Checklist <br /> J--] Vendor W-9 <br /> <br /> Distributed Copies <br /> I--I Other R. outing Instructions <br />Copies to originating Department <br /> <br />Department Head's Signature: <br /> <br />Date: <br /> <br />NOTES: <br /> <br /> INFORMATION TECHNOLOGY DIRECTOR <br />II (Applicable only for hardware/software purchase or related services) <br />IIThis document has been reviewed and approved by the Information Systems Director as to technical content. <br />II IT Director's Signature: Date: <br />II <br /> <br />REQUIRED APPROVALS <br /> <br />Does this contract require Board of Commissioner action? Yes [--I No [] Date of action: <br /> <br />Does this contract require County Manager action? <br /> <br />Yes r'-I No [] Date of action: <br /> <br />CONTRACT ADMINISTRATOR <br /> <br />Date Received: <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 />[] Pre-audit certification completed. Purchase Order/Encumbrance No.: <br />Notes: <br /> <br />Yes ['-I No [] <br />Yes [--~ No [] <br />Yes [] No [] <br /> <br />;ontract Administrator's nature: <br /> <br />Date: <br /> <br /> <br />