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MCDPH PURCHASE REQUEST FORM » PROGRAM SEQUENCE # << of a emi hf Repo PROCUREMENT SEQUENCE # OPRO32420 fame FY20 esd REQUESTING DIVISION / OFFICE ADMIN DISEASE CONTROL CLINICAL SERVICES PUBLIC HEALTH POLICY Opirector [COMMUNITY WELLNESS DOADMIN CorAL HEALTH Dorr OFIN EPIDEMIOLOGY Ohiv COPHARMACY Opup OR (COFAMILY HEALTH CULABORATORY CIREFUGEE HEALTH Drocjcrants — JJOPR CimevIcat Recoros Cistb Opts CVITAL REGISTRATION CITUBERCULOSIS Owic COMMUNITY TRANSFORMATION OTHER PROGRAM OPERATIONS COCOMMUNITY HEALTH INNOVATION o COCOMMUNICATIONS & MARKETING CscHOOL HEALTH AND WELLNESS CICOMMUNITY EMPOWERMENT COWoRKSITE HEALTH INNOVATION CI RYAN WHITE PROGRAM COHEALTHCARE INNOVATION FURNITURE REQUEST DATE SUBMITTED DATE NEEDED REQUEST TYPE 3/24/20 ASAP [p-card ClPurchase Order LIP.O. Modification GRANT / ORDERING DEPARTMENT SHIP TO ADDRESS / ATTENTION TO NAME COVID 19 RESPONSE TEAM MARICOPA COUNTY DEPARTMENT OF PUBLIC HEALTH Maricopa County Department of Public Health OFFICE OF PREPAREDNESS & RESPONSE Office of Preparedness and Response 4041 N CENTRAL AVE, SUITE 600 ESTIMATED DOLLAR AMOUNT PHOENIX, AZ 85012 $31,655.00 REQUESTOR NAME REQUESTOR PHONE # REQUESTOR EMAIL ADDRESS Cheryl Bucalo 602-506-6886 cheryl.bucalo@maricopa.gov FUND | DEPT UNIT. | ACTIVITY. APPROP OBJECT: | SUB.OBJ | DEPT OBJ Loc FUNCT. | PROGRAM | PERIOD %ORS 100 D860 8611 EPIR 1000 8040 11 COVD FY20 100% LINKS TO PRODUCT, ITEM NUMBERS, SERVICE DESCRIPTION, SCOPES OF WORK, JUSTIFICATION, AND SPECIFICATIONS Handwashing trailer to be used to service Homeless Communities Order # 81515HWA SUGGESTED VENDOR ap »/ VENDOR INFORMATION «°° SHIPPING OPTIONS Kuntry Kustom VENDOR' NUMBER (Standard Delivery Pick-up MA/MALL NUMBER ClExpedited Shipping Ona COMMODITY CODE i , APPROVALS ACCOUNTANT SIGNATURE Dalton Cason DATE MANAGER SIGNATURE _ DATE FINANCE SIGNATURE: F DATE iz ! PROCUREMENT'SPECIALIST ’ AWARDED VENDOR _ DATE PURCHASED TOTAL INVOICE AMOUNT JAKKS DATE REALLOCATED 9-3-deo t Mi