Contract Approval Request Form
To Be Completed by Requesting Department (#1-21)
1) Date of Request: 2/26/2024
2) Contract Type: Expense
3) Renewal Contract: Yes
4) Department Name: Human Resources
5) Department Contact: Rebecca Gilliam
6) Description: Consideration of approval of Interface EAP contract renewal.
7) PEID No: 400917
8) Req No:
9) Orgkey: 6123155023
10) Object Code: 5491704
11) Vendor: Interface EAP Inc.
12) Vendor Contract No: CM23111
Expenditure Budget/Revenue Projections
13) Fund Name: Employee Assistance Program
14) Fund #: 6123155023
15) Current Year Budgeted: 19,000
16) Current Year Projected: 19,000
17) Year 2:
18) Year 3:
19) Year 4:
20) Year 5:
21) Totals:
To Be Completed by Purchasing Department
22) Contract Start Date: 1/1/2024
23) Auto Renewal Contract: No
24) Bid No: NA
25) Contract End Date: 12/31/2024
26) Contract # Issued by Purchasing Department: CM23111
NOTES: HB1295 Requested