Contract Approval Request Form
To Be Completed by Requesting Department (#1-21)
1) Date of Request: 6/3/2024
2) Contract Type: Expense
3) Renewal Contract: Yes
4) Department Name: Human Resources
5) Department Contact: Angela Bleyle
Description: Consideration of execution of renewal contract with Pinnacle Medical Management Corporation for alcohol and drug testing.
6) PEID No: 709307
7) Req No:
8) Orgkey: 1101 155000
9) Object Code: 5412101
10) Vendor: Pinnacle Medical Management Corporation
11) Vendor Contract No:
Expenditure Budget/Revenue Projections
12) Fund Name: Contract Medical Services
13) Fund #: 1101155000
14) Current Year Budgeted: 2024 $28,000
15) Current Year Projected: $28,000
16) Year 2:
17) Year 3:
18) Year 4:
19) Year 5:
20) Totals:
To Be Completed by Purchasing Department
21) Contract Start Date: 6/1/2024
22) Auto Renewal Contract: No
23) Bid No: NA
24) Contract End Date: 5/31/2026
25) Contract # Issued by Purchasing Department: CM24219
NOTES: HB1295 Requested