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