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CPH Information Technology Support Services
Subscription & Membership Request
Fiscal - Subscription & Membership Requests
Requestor Information
Prepared by
*
Email
*
Phone
Division
*
Addiction Services
Administrative Services
Clinical Health
CPHI (Center for Public Health Innovation)
Environmental Health
Family Health
Health Commissioners Office
Neighborhood Social Services
Population Health
Sexual Health Promotion
Fiscal Information
Please enter your Grant Number
OR
General Fund DAX String below (
Click here for the DAX Conversion Listing
)
Order will not be processed without correct fiscal information.
Grant #
G50XXXX
Fund #
*
i.e. 2250, 2251, etc
Program
*
i.e. CW001, HE002, etc
Section 3
*
i.e. 500XXX
Section 4
i.e. HE09, HE27, etc
Subscription/Membership Information
Description of Subscription/Membership
*
Attach Subscription/Membership Information
*
Drop a file here or click to upload
Choose File
Maximum file size: 5MB
Upload contract/agreement if required
Total Cost
*
$
Vendor/Agency Name
*
Term Length
*
One Time
Monthly
Annual
Other
Term Length
Will the vendor accept a Purchase Order?
*
Yes
No
Is credit card the only payment option?
*
Yes
No
If this is a software subscription, has Health Technology reviewed/approved?
*
Yes
No
N/A
Approvals
Please double check
email address spelling
for accuracy.
Notifications will be sent to email addresses to request signatures.
Employee Signature
*
Clear
Supervisor's Email
*
Full Typed Name - Supervisor
*
Date
*
Supervisor Signature
*
Clear
Division Administrator's Name
Anita Clark
Audrey South
Beth Wilson
Danielle Ohms
Edward Johnson
Jenessa Teague
Josh Watters
Jo Taylor
Luke Jacobs
Marian Stuckey
Mysheika Roberts
Tami Langen
Tiffany Krauss
Division Administrator's Email
*
Full Typed Name - Division Administrator
*
Date
*
Division Administrator Signature
*
Clear
Fiscal Analyst's Name
Adam Hochstetler
Brandon Harris
Charles Yang
Jamie Hatkow
Jon Crego
Katie Pettiford
Lynaya Elliott
Susan Hager
Fiscal Analyst's Email
*
Full Typed Name - Fiscal Analyst
Date
*
Fiscal Analyst Signature
*
Clear
Notify Additional Viewers
Yes, I would like to notify someone of this request
Additional email recipients (view only)
Add email recipients (separate multiple addresses by comma)
If you are human, leave this field blank.
Submit