HomeMy WebLinkAboutReuqest FormORIGINATING DEPARTMENT: Purchasing Department
DEPT. CONTACT PERSON: Aimee Gandarilla EXT. x1906
NAME OF CONTRACTUAL PARTY/ENTITY: Public Health Trust of Miami -Dade dib/a Jackson Health
System
IS THIS AGREEMENT AS A RESULT OF A COMPETITIVE PROCUREMENT PROCESS? ❑ YES ❑ NO
AWARD/CONTRACT AMOUNT: Term Contract -First Renewal
FUNDING INVOLVED? ❑ YES ❑ NO
TYPE OF AGREEMENT:
❑ MANAGEMENT AGREEMENT .
❑ PROFESSIONAL SERVICES AGREEMENT
❑ GRANT AGREEMENT
❑ EXPERT CONSULTANT AGREEMENT
❑ LICENSE AGREEMENT
OTHER: (CONTRACT NO.) RFP No. 04-05-097(12)
CONTRACT TITLE: Medical Direction Services for EMS
❑ PUBLIC WORKS AGREEMENT
❑ MAINTENANCE AGREEMENT
❑ INTER -LOCAL AGREEMENT
❑ LEASE AGREEMENT
❑ PURCHASE OR SALE AGREEMENT
COMMISSION APPROVAL DATE: November 17, 2005 RESOLUTION NO.: R-05-0658 FILE ID: 05-01243
IF THIS DOES NOT REQUIRE COMMISSION APPROVAL, PLEASE EXPLAIN:
EXECUTION BY THE CITY MANAGER
Date
..,Signature/Print
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APPROVAL BY DEPARTMENTAL DIRECTOR
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SUBMITTED TO RISK MANAGEMENT
N/A
N/A
SUBMITTED TO CITY ATTORNEY
N/A
N/A
APPROVAL BY CHIEF
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APPROVAL BY CITY MANAGER
SUBMITTED TO AND ATTESTED BY CITY CLERK
N/A
N/A
ONE ORIGINAL TO CITY CLERK; ONE COPY TO CITY.
N/A
NIA
ATTORNEY"S OFFICE,''REMAINING gRIGINAL`{Sj_TO
DEPARTMENT
PLEASE ATTACH THIS ROUTING FORM
TO ALL DOCUMENTS
THAT REQUIRE
EXECUTION BY THE CITY MANAGER