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CITY OF SOUTH BEND, IN - ORDER FORM 2019 <br />First Name mmmmmmmmm �..... Last Name u <br />Title <br />........... ._..... <br />Phone Number <br />Email Address: <br />_..... _.._... .............................. ___.A ._.._.......... <br />Billing Address <br />............................... <br />Delivery Address <br />w. <br />Method of Invoicing All invoices will be sent electronically to the Email Address provided above unless otherwise specified in Special Invoicing Needs. <br />Special Invoicing Need <br />Vendor Accela,Inc. Customer City of South Bend,Vl'1` ( y <br />Signed By Signed By <br />Date <br />Date <br />Title of Authorized <br />.. ............................. ............ ._........_........................ <br />Title of Authorized <br />Si natoa <br />Signatory <br />Name (Print) of <br />Name (Print) of <br />Authorized ", kmatoav <br />Authorized S'iytnjtory <br />Customer I..... N Customer <br />Signed By I....... Signed By <br />Date <br />Date <br />Title of Authorized <br />Title of Authorized <br />Snato <br />,Si nator <br />Name (Print) of <br />Name (Print) of <br />ithoHre d Sittriatevv <br />Authorized SiR; natoiry <br />i I � 'e nrovided to the rielit and Customer inust provide PO # (If required). <br />�.g„�e. l�lno llO numt)a.a laa•ovided l.)rfol• to faavout.e isstaxarrce d2ate, <br />invoices I sued on this Order Forto will be valid without a PO reference, <br />Page 4 of 4 I Order Form <br />Form Approved by Legal (v.1 09/05/2018) <br />