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[DOC DocuSign <br /> SI Envelope 01 1B6AFC45-B5BD-4305-A94im i r-n Au CONTRACT REQUISITION FORM <br /> UCUSIC3NPILUT 2016 AM MI <br /> _�_-_ <br /> CONTRACTOR/VENDORNAME: Orange Countv VENDOR#1000015376 <br /> CONTRACTOR NAME&E-MAIL(INDIVIDUAL E-SIGNING ONBEHALFOF THE CONTRACTOR): <br /> Bonnie Harnmersley,David Hunt bhammersle gran ecount nc, av dhynL@orancyecount nc, ov <br /> Print Name E-Mail Address <br /> TYPE OF CONTRACT:New Renewal X Amendment X Services_ Goods_ Consulting_ Construction_ Lease Other Inter-local Agreement <br /> SCOPE OF WORK: Provide Roadside Graohic Services to Orange Countv via Durham Countv Sign Shot) <br /> CONTRACT AMT:Revenue NTE S25,000.00 CONTRACT TERM:Julv 1,2017—June 30,2018 RFP/IFB/RFQ#: N/A <br /> ITEM FUND COST CENTER G/L ACCOUNT WBS ELEMENT GRANT NUMBER TOTAL Increase(I)or ADDITIONAL <br /> LINE# (Grants/Projects Only) Decrease INFO <br /> 1 1001010000 4190490000 5200160100 Revenue Sign Shop <br /> 2 <br /> 3 <br /> RISK MANAGER Contract Requires Risk Management Review/Approval? YES NO X COUNTY ATTORNEY <br /> Signature: Date: <br /> Contract Requires BOCC Approval? YES NO X Date ofBOCC Approval: Reviewing Attorney: See attached e-mail Date: 09/11/17 <br /> REQUISITIONER ,K AGWINGMANAGER <br /> PrintedName/Title: Eli McCutcheofL C&CS �o�sA Date: 9/13/2017 �a��u��.,� �o! � Date:9/20/2017 <br /> E-Mail Address: emeeutehean'adeane. av <br /> 9/18/2017 �az�d 'sta- nature <br /> 141622BCFAB413461... <br /> Lam] T;IENT HEAD OR DESIGNEE(Individual E-Signing Contract) CHIEF FINANCIAL OFFICER <br /> bttV�6 �IVOIVb Date: 9/20/2017 N/A Date: <br /> Docusign E-Signature Docusign E-Signature <br /> Printed Name/Title: Motiryo Keambiroiro,Director of General Services WUNJX MA NAGER <br /> n L�Why"ANgnature L� A-. yayUs Date: 9/22/2017 <br /> E-Mail Address:mkeambirairadeane.�av <br /> - - <br /> Additional Comments/Instructions by Department: Q.Vf.KbT.O THE BOARD <br /> E�?f&i6FWA746gnature l(td—�tl.. eA.V�cLr_-eV� V"S Date: 9/27/2017 <br /> Purchasing Comments: Compliant <br /> APerry <br /> FUNDS RESERVATION# 18-436 <br />