CHIEF PROCUREMENT OFFICER (CPO)
SIGNATURE REVOCATION FORM – DESIGNEE
(SAMS PROCEDURE 15.20.99)
The Chief Procurement Officer (CPO) Signature Revocation Form
Designee form is used to revoke specimen signatures for
designees authorized to sign or affix the signature of the CPO
Chief Procurement Office (CPO) Signature Revocation Form – Designee forms must be emailed with the area of jurisdiction
included in the subject line and the name of the individual revoked 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 revocation 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 PREVIOUSLY AUTHORIZED TO SIGN OR AFFIX THE CPO SIGNATURE (Type/Print the name of
the individual previously authorized to sign or affix the signature of the Chief Procurement Officer):
4) EFFECTIVE DATE OF REVOCATION*: ______________________________________________________________
5) By signing this form, I am requesting that the Comptroller’s Office revoke signature authority for the above-named Chief
Procurement Officer designee on the effective date shown above. I hereby certify that the original signed document
exists in my possession.
Signature of Authorized Representative Type/Print Name of Authorized Representative
Type/Print Title of Authorized Representative
*Enter the date the revocation is effective. Do not enter the current date unless it is the effective date for this revocation.