Contract Approval Request Form
To Be Completed by Requesting Department (#1-21)
1) Date of Request: 10/18/2024
2) Contract Type: Expense
3) Renewal Contract: Yes
4) Department Name: Contract Services
5) Department Contact: Veronica Van Horn
6) Description: EMS for Kemah and Clear Lake Shores
7) PEID No: 431945
8) Req No:
9) Orgkey: 1101 440100
10) Object Code: 5451104
11) Vendor: Galveston County Health District
12) Vendor Contract No:
Expenditure Budget/Revenue Projections
13) Fund Name: General Fund
14) Fund #: 1101
15) Current Year Budgeted: $129,250.00
16) Current Year Projected:
17) Year 2:
18) Year 3:
19) Year 4:
20) Year 5:
21) Totals:
To Be Completed by Purchasing Department
22) Contract Start Date: 10/1/2024
23) Auto Renewal Contract: Yes
24) Bid No: NA
25) Contract End Date: 9/30/2025
26) Contract # Issued by Purchasing Department: CM23108
NOTES:
FY25 - HB1295 not required