Contract Approval Request Form
To Be Completed by Requesting Department (#1-21)
1) Date of Request: 12/30/2024
2) Contract Type: Expense
3) Renewal Contract: No
4) Department Name: General Government
5) Department Contact: Veronica Van Horn
6) Description: Consulting agreement for Inmate Medical with UTMB
7) PEID No:
8) Req No:
9) Orgkey: 1101-110000
10) Object Code: 5481000
11) Vendor: Alliant
12) Vendor Contract No:
Expenditure Budget/Revenue Projections
13) Fund Name: General
14) Fund #: 1101
15) Current Year Budgeted:
16) Current Year Projected: $10,000.00
17) Year 2:
18) Year 3:
19) Year 4:
20) Year 5:
21) Totals:
To Be Completed by Purchasing Department
22) Contract Start Date: Click or tap to enter a date.
23) Auto Renewal Contract: Choose an item.
24) Bid No:
25) Contract End Date: Click or tap to enter a date.
26) Contract # Issued by Purchasing Department:
NOTES: