CHIEF PROCUREMENT OFFICER (CPO)
SIGNATURE REVOCATION FORM
(SAMS PROCEDURE 15.20.99)
The Chief Procurement Officer (CPO) Signature Revocation Form is used to revoke specimen signatures submitted to the
Comptroller’s Office for the previous Chief Procurement Officer and all associated designees.
Chief Procurement Officer (CPO) Signature Revocation 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 PREVIOUS CHIEF PROCUREMENT OFFICER (Type/Print the name of the previous 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 and all associated designees 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.