PO RE FLOURIDE VARNISH WITH ADHS.PDF

Page 1 of 1
ARIZONA STATE CONTRACT
CONTRACT RELEASE
ProcureAZ Purchase Order No,; ADHS13-031613:3
Organizational Reference No.: E0179544
Issued: 07/1512014
Vendor Number: 000010983 Arizona Department of Heath Services
Maricopa County Public Health Bureau of Women and Children's Health
1001 N CENTRAL AVE 150 N. 18th Avenue, Suite 320
STE 500 Phoenix, AZ 85007
Phoenix, AZ 85004 US
Email: procure@azdhs.gov
Contract No.: ADHS13-031613 (602) 364-1400
Title: Fluoride Varnish Program
MAIL INVOICE IN DUPLICATE TO:
Arizona Department of Health SerVices
Bureau of Women and Children's Health
150 N. 18th Avenue, Suite 320
Phoenix, AZ 85007
US
Email: procure@azdhs.gov
(602) 364-1400
Release Instructions
TERMS AND CONDITIONS set forth in our Bid, Quotation, or Purchase Order
are incorporated herein by reference and become a part of this order.
Account Code: 15-96519-45000-6811- Payment Terms: Net 30
Shipping Terms:
Solicitation (Bid) No.: Delivery Calendar Day(s)A.R.O.: 0
Item Description Requisition Quantity Unit Unit Price Total
Class-item 948-28
PO EFFECTIVE 7/1/14 - 6/30/15 *** CONTRACT EFFECTIVE 9/1/12 -
8/31117 *** CONTRACTOR TO INVOICE ACCORDING TO CONTRACT
1 PRICE SHEET AS FOLLOWS: PERSONNEL = $32,765.00 ***ERE = 1.0D YR $ 179,749,00 $ 179,749,00
$15,084.00 *** PROFESSIONAL & OUTSIDE SERVICES = $80,640.00 ***
TRAVEL EXPENSE (IN STATE) = $801.00 *** OUT OF STATE TRAVEL =
$0.00 *** OPERATING EXPENSES = $30,518.00 *** OTHER NON-
CAPITAL EQUIPMENT = $3,600.00 *** INDIRECT (IF AUTHORZED) =
$16,341.00 ***TOTAL ANNUAL CONTRACT AMOUNT IS
***** Fluoride Varnish Services
TOTAL: $ 179,749.00
Approved By: Dee Vlahos
Phone No.: (602) 364-1425

C-86-13-024-3-03 ATTACHED TO AND A PART OF
PURCHASE ORDER NO. ADHS13-031613:3
Fluoride Varnish Program
IN WITNESS WHEREOF, the parties agree to enter into this Agreement:
FOR AND ON BEHALF OF
MARICOPA COUNTY
By
Chairman, Board of Supervisors
Date
ATTEST:
Clerk of the Board
Date
APPROVED AS TO FORM:
Attorney for Maricopa County
Date