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STATE OF COLORA O <br /> CONTRACT ROUTING/DOCUMENON FORM <br /> K <br /> SECTION 1 CONTRACT INFORMATION/ENCUMBRANCE REQUEST <br /> r' <br /> AGENCY NA E COFRS AGENCY D LPHb) DIVISION OR PROGRAM lfw contract rew and Wig purposes) <br /> r �eo o <br /> ROUTING NUMBER (Fiscal Year) (Contract Number) (Optional) AMENDS ROUTING NUMBER NUMBER OF COPI ATTA ED <br /> © O(0 <br /> TURN C TRACT T PHONE FAX <br /> S (� <br /> AGENCY/PIVISION PROGRAM CONTACT PHONE <br /> AGENCY ENCUM A E CONTACT <br /> PHONE FAX <br /> CONTRACT INFORMATION Q Q I 71 2 S 9 5 <br /> Statewide Master Contract Log (SMCL) Type Multi-Y iSnnTr)a t ❑Yes �No <br /> ❑Delegated Contract 0 Non-Delegated Contract $3 MYC End Date <br /> ❑Original Contract ❑Amendment Ch nge/Order ❑ S plement ❑ Lease <br /> Vendor Name (As Entered on Vendor File) � ndor Code g <br /> Contract Encumbrance Amount$ loz5b <br /> If Amendment, Change Order, or Supplement, is this an...X Increase OR ❑ Decrease <br /> Appropriation Info ation: ❑ Long Bill ❑ Spe 'al Bill State Fiscal Year Bill Number <br /> Comments: <br /> (For DOAC use o y) <br /> SECTION 2 METHOD OF PROCUREMENT <br /> ❑ Formal RFP ❑ Informal RFP ❑ Sealed Bid RFP/Bid Number <br /> ❑ Sole Source ❑ Emergency ❑ Special Circumstance <br /> ❑ Refer to Pre-Approved Justification Attached ❑Other(Identify) <br /> Approval is dependent upon adherence to State Procurement Rules. Failure to reference the RFP/Bid number or to include a pre-approved justification for <br /> Sole Source,Emergency,or Special Circumstance procurement will cause delays in obtaining a contract approval. <br /> SECTION 3 ROUTING SEQUENCE <br /> Agency Release Date _- _) Signature �, � <br /> 21L-tj� <br /> DATE RECEIVED SIGNATURE DATE FORWARDED SIGNATURE <br /> DIVISION OF PURCHASING <br /> RETURNED TO DIVISION OF PURCHASING <br /> DEPARTMENT OF ADMINISTRATION <br /> DEPARTMENT OF PERSONNEL <br /> RETURNED TO DEPARTMENT OF PERSONNEL <br /> STATE BUILDINGS DIVOON <br /> ATTORNEY GENERAL <br /> RETURNED TO THE ATTORNEY GENERAL <br /> DIVISION OF ACCOUNTS AND CONTROL <br /> RETURNED TO ACCOUNTS AND CONTROL <br /> AGENCY <br /> OTHER <br /> I NOTE: Contracts must be in compliance with the State Controller's Fiscal Rules(Chapter 3),the Colorado Procurement code and rules,and the Department of Personnel Statutes and rules The above routing blocks <br /> must indicate the numeric routing sequence for the attached contract The Agency Release Date and Signature are to be completed by the agency representative initiating the CONTRACT/ROUTING <br /> DOCUMENTATION FORM <br /> ORIGINAL CONTRACTS and AMENDMENTS: ATTACH the white and yellow copies to the contract or amendment being routed SEND the goldenrod copy to the agency accounting office RETAIN the pink copy for <br /> your records <br /> 395-53-0 1-0085(113 12/92) <br />