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:
obligations@illinoiscomptroller.gov
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):
n
Governor
n
Comptroller
n
Capital Development Bd (Construction)
n
Lt. Governor
n
Treasurer
n
Dept of Transportation (Construction)
n
Attorney General
n
Governor’s Office of Management/Budget
n
Institutions of Higher Education
n
Secretary of State
n
Auditor General
n
General Services
n
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.
SCO-471-A 9/2019
