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' ~ r~nr~iTQe('T RFVIFW CHFFT <br />...... ~ . . .., . <br />~e~son Sending: ~ ~ ~-rQ fPn Department Name: ~~,~,1~.~ ~ - ~ ~ ~,~. <br />Date Sent• ~ i~i~~e 1 <br />1 he attacheU: (CIRCL <br />Contract Amendment #~" Grant Lease Intergov't Agreement <br />INCOMING FUNDS? YES NO (CIRC~E ONE) <br />Contractors ~ y- Ej~~C K~~ ~~~' ~~"1 C <br />Name: <br />Date From: ~~j !~% Date To: CrC} i~ ~~~~ ~ L~ ~~-. <br />Amount of Contract or Amendment: ~ ( 3 ~ ~ ~; ( ? ((,~ J ~*' , ~~ ~ ~~~ ~,}d (~c ~ <br />If an Amendment, New Contract Total =$n/a <br />Certificates of Liabiliry Workers Comp ~f no insurance atcached, why noc? <br />Insurance c~'«ie °~e~ c~~~~iP ~~P~ <br />Attached: <br />Yes No <br />Yes No <br />Process taken to select contractor: <br />Verbal quote: Written quote: RFP: Competitive Bid: Renewal: <br />(Attach copy for reference) <br />Description of Contract Services: <br />4~ vn4~ n~ ~n.'~ac,i-- ~-~, i r-i c I~i..~, -~ c. ~-Y-- c; v,~ ~- C-~ ~~ 3, 3 sc> <br />-4t~ cid c:~i ~i~E..~n QE .Sk,~~u ~ ~e S~-l-t> > r~ ~~ ~ cLC c~V~c• h.~t. fc= c fir-~ ( e'c' c_~.~-r~ <br />~{~ G~::~~1C~ ~ tt-1l~ '(1'~~C ~'l~r~~C~ ~ 4' r-~Q~_+Y~CCc~ v_.~.~:.Y-.<l C~ti G~::-,;, <br />J <br />For Support Services Use ~ - <br />Date Contract Received• ~~• ~,j ~ ~ ! Date Scheduled on BOC Agenda: <br />Authorization for Health Administration to Additional Comments: <br />half of BOC: <br />b <br />i <br />gn on <br />e <br />s <br /> <br /> yes no <br />~ <br /> ; <br />Staff Review Signatures: ~` <br /> ~ <br /> j~ r~~,~,..~~.w_ <br />~ <br /> ~al Counsel date <br />Contracts Coordinator date <br /> Risk Manager date <br /> ~ ~ <br />'~ <br /> ~ <br />~.a: <br />~.~4,../r~ ~ ~,~~.~r/ <br />~• <br />aly.ufw..e. <br />Review.CON 8/99 <br />