Laserfiche WebLink
Asset Transfer Form Urban Area Security Initiative Grant FY2007 JA740969 <br />Transfers from County to Community, Hospital or Agency <br />" to be completed by community or agency receiving equipment <br />"Item Description 'Quantity Price per Unit Total Price Vendor PO # Lot # Expiration Date Transfer Date <br />Duodote Auto injector 90 $42.23 $3,800.70 Amerisochi, Inc 1002699 9AE645 June, 2013 <br />Diaze am 10m in 2ml auto-injector 15 $31.87 $478.05 Amerisochi, Inc 1002699 9D1347 Au , 2014 <br /> <br /> <br /> <br />Total Kits: <br />3 ALS <br />3 BLS <br /> <br />Total $4,278.75 <br />I acknowledge and concur that -North Olmsted Fire <br />Department (name of community/hospital/agency) has <br />received the above assets in the correct amounts and in <br />satisfactory condition. I (we) furthermore agree to abide by all <br />requirements of the Homeland Security grants relative to the <br />purchases of this equipment. I (we) authorize payment of the <br />attached invoice(s) for the assets listed above. <br />Received <br />Signed pity/Agency Representative <br />Pri Nam <br />/l //J . <br />Date <br />Payment of the attached invoice(s) is approved for the assets listed above. <br />Cuyahoga County Signature <br />Cuyahoga County Print Name <br />Date <br />Ed E <br />Distributed By <br />