2004/12/22 Council Agenda Packet

' J Intergovernmental Cooperative Purchasing Agreement for Political Subdivisions Page 4 OSP has assigned you customer number, . Please provide this number when ordering from contracts or communicating with OSP. (Completed by OSP,will be returned to you in executed copy) Organization contact information: Contact Person (To whom contract documents and related communications are to be mailed or faxed). Name: Address: City,St.Zip Phone Number. Federal Id#: FAX Number: Email Address: The undersigned understands and agrees to the terms and conditions of this agreement and attests that the expense/budget category checked above is true and correct. Political Subdivision Authorized Signature: Applicant must provide an authorized signature. Name: Address: Phone Number: Date: What is the most significant reason for joining the State Purchasing Cooperative? Specific Contracts How did you hear about the State Purchasing Cooperative? Trade Show ❑ Customer Service Visit ❑ Procurement Staff ❑ Other(please specify) Office of State Procurement Authorized Signature: Name: Date: 13