Contract Approval Request Form
To Be Completed by Requesting Department (#1-21)
1) Date of Request: 9/23/2024
2) Contract Type: Expense
3) Renewal Contract: Yes
4) Department Name: Professional Services
5) Department Contact: Veronica Van Horn/Froy Arcega
6) Description: UTMB Physician Assistant
7) PEID No: 402812
8) Req No:
9) Orgkey: 1206-443300
10) Object Code: 5412133
11) Vendor: UTMB
12) Vendor Contract No:
Expenditure Budget/Revenue Projections
13) Fund Name: Child Welfare
14) Fund #: 1206
15) Current Year Budgeted:
16) Current Year Projected: $169,000.00
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: No
24) Bid No: NA
25) Contract End Date: 9/30/2025
26) Contract # Issued by Purchasing Department: CM23080
NOTES:
FY25 BA of $69,000.00 on 9/30/24 agenda - HB1295 not required