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P.O. Box 387 - 99 Water Street, Markleeville, CA 96120 (530) 694-2287 / Fax (530) 694-2491 Web Page - http://www.alpinecountyca.gov COUNTY OF ALPINE Administration Carol McElroy- CAO/DOF Sarah Simis- Deputy CAO to Personnel/Risk Management Clerks Use Only: Contract/Amend No: Alpine County Purchasing Agent Approval Request Form Department: Name of Services/Contractor/Consultant/Third Party: Name of Supplier/Vendor: Start Date: End Date: Not to Exceed/Rate: Source: $3,001-$25,000 $25,001-$50,000 $50,001 and up Dept Head Authorized Dept Head/CAO BOS Approval No Notice or Comp Bid RFP: Yes or No Explain Appropriation in Departmental Budget Insurance Certificate(s) provided to Department Contract Signed by “Consultant” Approved as to Form by County Counsel Reviewed and Approved by CAO When fully executed, scan Contract with Insurance Certificates to Assistant County Clerk Department Head Signature: Date: SIGN