Contract Approval Request Form
To Be Completed by Requesting Department (#1-21)
1) Date of Request: 10/14/2025
2) Contract Type: Other
3) Renewal Contract: No
4) Department Name: Road & Bridge
5) Department Contact: Zach Smith
6) Description: Fuel Access Agreement
7) PEID No:
8) Req No:
9) Orgkey:
10) Object Code:
11) Vendor:
12) Vendor Contract No:
Expenditure Budget/Revenue Projections
13) Fund Name:
14) Fund #:
15) Current Year Budgeted:
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: 10/25/2025
23) Auto Renewal Contract: Yes
24) Bid No: N/A
25) Contract End Date: 10/25/2026
26) Contract # Issued by Purchasing Department: 238775 (SC-000980)
NOTES: EVERGREEN