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CONTRACT REQUISITION FORM -664 <br /> CONTRACTORIVENDOR NAME: ,VCc VENDOR# <br /> ADDRESSICITY/ST/ZIP: 7-A V , ail N . ] 5';• W21�+ ^1 N� ;7 ! cs. ,� 1► <br /> v* <br /> TYPE OF CONTRACT:New— Renewal— Amendment— Services Goods^ Consulting_ Construction_ Lease_Other w�►••CAg�4 <br /> � rrt+ <br /> DESCRIPTION/SCOPE OF WORK: C+r r rr DC tom, ,y+r <br /> v- <br /> r't" <br /> CONTRACT AMT: Q CONTRACT PERIOD: EaAryetZ _ RFP/IFBIRFQ#: N <br /> FUNDING SOURCE: General— State_ Federal_ Grant_ Other <br /> 1TEM FUND COST CENTER G/L ACCOUNT WBS ELEMENT GRANT NUMBER TOTAL 1/D ADDITIONAL INFO <br /> LINE# <br /> I � (GrantslPrajects Only) <br /> 2 <br /> 3 <br /> COUNTY ATTORNEY COMMENTS: <br /> Contract requires Risk Management approval? YES— NO <br /> RISK MANAGER Signature: Date: <br /> Contract requires BOCC approval? YES✓/NO_ Date of BOCC Approval: �� p� Reviewing Attomey: ]late: <br /> INITIATING DEPARTMENT(Required) BUDGET DIRECTOR(Required only for Business Area 9800) <br /> By: Date: /1 j s By: Date: <br /> COUNTY M FINANCE OF I R Pre.audit Ce I n Comple Yes�No <br /> L-- <br /> By' Date: !S- Signature: Date <br /> CLERK TO E BOARD PURCHASING <br /> By: Date: By: Date: (e <br /> IT DIRECTOR Purchasi g Comments: <br /> By: Date: <br /> FUNDS RES DOC ID# /6- I11 l <br />