Agenda - 01-21-2010 - 4j - Laserfiche WebLink

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9 *Request for Information To expedite service, please complete the following blanks relevant to your agency's administrative/elective personnel and return the completed form to H-GAC, Cooperative Purchasing Program, P.O. Box 22777. Houston, TX 77227-2777. Name of End User Agency: County Name: (Municipality /County /District /etc.) Mailing Address: (StreetAddress/P.O. Box) (City) (State) (ZIP Code) Main Telephone Number: {~ - FAX Number: (~ - Physical Address: (Street Address, if d~erent from mailing address) (City) (State) (ZIP Code) Web Site Address: Authorized Official: (City manager /Executive Director /etc.) Mailing Address: (Street Address/P. O. Box) (City) (State) (ZIP Code) Official Contact: (Purchasing Agent/Auditor etc.) Mailing Address: (Street Address/P. O. Box) (City) (State) (ZIP Code) Official Contact: (Public Works Director/Police Chief etc.) Mailing Address: (City) Official Contact: (Street Address/P. D. Box) (State) (EMS Directar/Fire Chief etc.) (ZIP Code) Mailing Address: (Street Address/P.O. Box) Title: Ph No.. ~~ - Fx No.. ~~ - E-Mail Address: Title: Ph No.: ~~ Fx No.. ~~ Email Address: Title: Ph No.: (~ Fx No.. ~~ Email Address: Title: Ph No.: L_) Fx No.. ~) Email Address: (City) (State) (ZIP Code)