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*Request for Information Please sign and return the Interlocal Contract,along with this completed form,to H-GAC by emailing it to cpcontractfax(a,h-gac.com or by faxing it to 713-993-2424.The contract may also be mailed to: H-GAC Cooperative Purchasing Program P.O.Box 22777 Houston TX 77227-2777 Name of End User Agency: County Name: (Municipality/County/District/etc.) Mailing Address: (Street Address/P.O. Box) (City) (State) (ZIP Code) Main Telephone Number: ( ) FAX Number:( ) Physical Address: (Street Address, if different from mailing address) (City) (State) (ZIP Code) Web Site Address: Official Contact: Title: (Point of Contact for HGACBuy Interlocal Contract) Ph No.:( ) - Mailing Address: Fx No. :( ) - (Street Address/P.O. Box) E-Mail Address: (City) (State) (ZIP Code) Authorized Official: Title: (Mayor/City Manager/Executive Director/etc.) Ph No.:( ) - Mailing Address: Fx No. : ( ) (Street Address/O.O. Box) E-Mail Address: (City) (State) (ZIP Code) Official Contact: Title: (Purchasing Agent/Auditor etc.) Ph No.:( ) Mailing Address: Fx No. :( ) - (Street Address/O.O. Box) E-Mail Address: (City) (State) (ZIP Code) Official Contact: Title: (Public Works Director/Police Chief etc.) Ph No.:( ) - Mailing Address: Fx No. : ( ) - (Street Address/O.O. Box) E-Mail Address: (City) (State) (ZIP Code) Official Contact: Title: (EMS Director/Fire Chief etc. ) Ph No.:( ) - Mailing Address: Fx No. : ( ) - (Street Address/O.O. Box) E-Mail Address: (City) (State) (ZIP Code) *denotes required fields