Rev. Date: March 2020
PURPOSE STATEMENT:
REVIEWERS DATE RECEIVED: DATE SIGNED:
YES NO Undecided Review Only SIGNATURE:
REVIEWER 1 NAME:
RECOMMEND:
COMMENTS:
DATE RECEIVED: DATE SIGNED:
YES NO Undecided Review Only SIGNATURE:
REVIEWER 2 NAME:
RECOMMEND:
COMMENTS:
REVIEWER 3 NAME: DATE RECEIVED: DATE SIGNED:
RECOMMEND: YES NO Undecided Review Only SIGNATURE:
COMMENTS:
CFO OR CEO : DATE RECEIVED: DATE SIGNED:
RECOMMEND: YES NO Undecided Review Only SIGNATURE:
COMMENTS:
SIGNATURE COORDINATION FORM INITIATION
ORIGINATOR:
RETURN TO:
TRACKED BY (Choose One): Originator
START DATE:
MAIL* RETURN BY DATE:
PROPOSED START DATE:
REQUEST TYPE
INTERNAL Department: Program:
EXTERNAL W9 REQUIRED? Yes No INSURANCE CERTIFICATE REQUIRED? To Vendor From Vendor
CONTRACT INFORMATION (If applicable) CRI CHI CRFI CRAI RYSI
NAME OF CONTRACT: CONTRACT #:
REVIEWER IDENTIFICATION - The action requested is for the following dollar amount: Between $0 – $500 Between $2,500 – $49,999 (Purchasing/ CFO review)
Between $500 – $2,499 (Purchasing review) $50,000 and Above (Purchasing/ CFO/ CEO review)
ACTION
NEW MODIFICATION (extensions/renewals) RFP OTHER (INTERNAL):
Executive Assistant
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