CHIEF PROCUREMENT OFFICER (CPO)
SIGNATURE AUTHORIZATION FORM
(SAMS PROCEDURE 15.20.98)
The Chief Procurement Officer (CPO) Signature Authorization Form is used to provide specimen signatures to the Comptroller
for persons authorized to sign the CPO approval line on Late Execution Waiver Requests.
Chief Procurement Officer (CPO) Signature Authorization Forms must be emailed with the area of jurisdiction included in the
subject line and the name of the authorized individual in the body of the email to:
The original signed document must be maintained at the office of the Chief Procurement Officer.
Each form must be
scanned as a separate document. Multiple forms can be sent in one email.
ALL FIELDS ARE REQUIRED
1) CONTACT INFORMATION (The individual to be contacted regarding this signature authorization form):
Name (Type/Print): ____________________________________________________________________________
Phone Number: ______________________________________________________________________________
Email Address: ______________________________________________________________________________
2) AREA OF JURISDICTION (Check one):
Capital Development Bd (Construction)
Dept of Transportation (Construction)
Governor’s Office of Management/Budget
Institutions of Higher Education
Secretary of State
Other (Please specify):_________________________________________________________________________
3) NAME OF PERSON AUTHORIZED TO SIGN OR AFFIX CPO SIGNATURE (Type/Print the name of either the Chief
Procurement Officer or designee authorized to sign or affix the signature of the Chief Procurement Officer):
4) SPECIMEN SIGNATURE (The designee must sign [not print]/affix the Chief Procurement Officer’s name followed by his/her
name precisely as it will appear on Late Execution Waiver Requests–initials are not acceptable):
5) EFFECTIVE DATE OF AUTHORIZATION*: ____________________________________________________________
I certify that I am the Chief Procurement Officer. I hereby approve the signature delegation authorized above for the purposes
of signing Late Execution Waiver Requests. I hereby certify that the original signed document exists in my possession.
Signature of Chief Procurement Officer Type/Print Name of Chief Procurement Officer
*Enter the effective date authorization is granted. Do not enter the current date unless it is the effective date for this authorization.
CPO signature is a stamp.