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DOCUSIGN INTERNAL CONTRACT REQUISITION FORM <br />CONTRACTOR/VENDOR NAME: Orange County VENDOR #1000006546 <br />CONTRACTOR NAME & E-MAIL (INDIVIDUAL E-SIGNING ON BEHALF OF THE CONTRACTOR): <br />Print Name: Bonnie Hammersley, Laura Jensen E-Mail Address: bhammersley@orangecountync.gov , ljensen@orangecountync.gov <br />TYPE OF CONTRACT: New __ Renewal X Amendment X Services X Goods __ Consulting __ Construction __ Lease __ Other ___________ <br />SCOPE OF WORK: Provide Roadside Graphic Services to Orange County via Durham County Sign Shop <br />CONTRACT AMT: Revenue CONTRACT TERM: July 1, 2022 – June 30, 2023 RFP/IFB/RFQ#: <br /> FUNDING SOURCE: General X State ___ Federal ___ UNIFORM GUIDANCE (UG) PROCEDURES APPLICABLE? YES ___ NO X <br />ITEM <br />LINE# <br />FUND COST CENTER G/L ACCOUNT WBS ELEMENT <br />(Grants/Projects Only) GRANT NUMBER MATERIAL <br />GROUP# <br />TOTAL I/D ADDITIONAL INFO <br /> 1 1001010000 4190490000 5200160100 0026 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 of BOCC Approval: Reviewing Attorney: _____________________________________________ Date: _______________________ <br />REQUISITIONER PURCHASING MANAGER <br />DocuSign E-Signature: __________________________________Date: 7/21/2022 ______________________________________________Date:________________ <br />Print Name/E-Mail: Tom Kutch tkutch@dconc.gov Docusign E-Signature <br />DEPARTMENT HEAD OR DESIGNEE CHIEF FINANCIAL OFFICER <br />DocuSign E-Signature: ___________________________________Date: _____________ ______________________________________________Date:________________ <br />Print Name/Title: Motiryo Keambiroiro, Director of General Services Docusign E-Signature <br />E-Mail Address: mkeambiroiro@dconc.gov <br />COUNTY MANAGER <br />______________________________________________Date:________________ <br />Docusign E-Signature <br />CLERK TO THE BOARD <br />______________________________________________Date:________________ <br />Docusign E-Signature <br />FUNDS RESERVATION# ____________________________________ <br />IS&T DEPT <br />Purchasing Comments: ______________________________________________Date:________________ <br />Docusign E-Signature <br />FY2022 <br />Additional Comments/Instructions by Department: <br />23-394 <br />COMP <br />see attached <br />N/A <br />8/8/16 <br />Initial Approval <br />N/A <br />THE LEGAL APPROVAL DOCUMENT IS ATTACHED TO THE FR IN SAP <br />DocuSign Envelope ID: 95AE5C9E-D7FE-4D88-8E7F-70E9DC13D623 <br />9/13/2022 <br />9/13/2022 <br />9/20/2022 <br />9/20/2022