Fillable Contract/agreement Cover Sheet - City Of San Jose printable pdf download

Contract/agreement Cover Sheet - City Of San Jose

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Clerk’s use only

CONTRACT/AGREEMENT COVER SHEET

TO:

CITY MANAGER

New Contract

(CM signature required)

Amendment/Change Order (List #)

CITY CLERK

(City Manager signature not required)

VIS Code (if known)

Original Contract CHAD # if known

Name of Contractor:

<-click

Business Contact Email Address

Business Tax License #

Phone number

Amount of contract now: Different than the original?

Term of THIS agreement:

Yes

Start date:

End date:

Revenue?

Yes

Term of ORIGINAL agreement:

Amount of Original Contract:

Start date:

End date:

RETROACTIVE Agreement?

Yes

Please Explain:

Department : Choose an item.

Dropbown Box

Airport

Dept. Contact Name:

Department Contact Phone:

Type of Contract:

Form 700 Required?

Council Date:

Council Item #

Resolution #

Yes Attached?

Check box if YES

300 Character Max

Description of contract: (What work will the contractor accomplish? Be Specific.)

Date

RFB

RFP

RFQ

Sole Source?

Description of selection process below:

Vendor Address & Notes

CONTRACT & INSURANCE VERIFICATION (MANDATORY) Please initial and provide description of insurance for ALL

contracts valued $269,999 and less. Risk Management will verify insurance for contracts valued at $270,000 and above.

<-sign here

I attest that the insurance verification of this contract have been met and all information is correct including policy limits, policy terms and City of San

José named as “Additional Insured.” [if this contract should be exempt from insurance requirements, please note why in the box below] Contract will not be processed if needed insurance

requirements or insurance proof is missing.

Description of Insurance exemption

Coordination:

Department Head Signature:

City Attorney’s Office (Required)

Human Resources

_________________________________Date:____________

Risk Management

Other: __________________

Office of the City Manager Signature:___________________________________________DATE:________________________

Rev. #2 - 2016-0225