Contract 2023-002A RDocuSign Envelope ID: 57C6B811-6ABF-48CF-BOA1-5C19445C75E1
DocuSign, Inc. Offer Valid Through: Jan 12,
DocuSign 221 Main Street, Suite 1550 2024
San Francisco, CA 94105 Prepared By: John Conlon
Quote Number: Q-01377060
ORDER FORM
Address Information
Bill To:
City of Clermont
685 West Montrose St.,
Clermont, FL, 34711
United States
Billing Contact Name:
Freddy Suarez
Billing Email Address:
fsuarez@clermontfl.org
Billing Phone:
352-241-7350
Order Details
Order Start Date: Jan 13, 2024
Order End Date: Jan 12, 2025
Billing Frequency: Annual
Products
eSignature Business Pro Edition - Envelope SUB-2134919-1
Subs.
Premier Support - eSign SUB-2134919-1
Product Details
eSignature Envelope Allowance: 1,100
Ship To:
City of Clermont
685 West Montrose St.,
Clermont, FL, 34711
United States
Shipping Contact Name:
Freddy Suarez
Shipping Email Address:
fsuarez@clermontfl.org
Shipping Phone:
352-241-7350
Payment Method: Check
Payment Terms: Net 30
Currency: USD
Jan 13, 2024 Jan 12, 2025
Jan 13, 2024 Jan 12, 2025
1,100 $3,696.00
1 $554.40
Grand Total: $4,250.40
Overage/Usage Fees
eSignature Business Pro Edition - Envelope Subs. (Per Transaction): $5.80
DocuSign Envelope ID: 57C6B811-6ABF-48CF-BOA1-5C19445C75E1
Order Special Terms
Terms & Conditions
This Order Form is governed by the terms Master Services Agreement available online at:
httiDs://www.docusign.com/legal/terms-and-conditions/msa and the applicable Service
Schedule(s) and Attachments for the DocuSign Services described herein available online at
httiDs://www.docusign.com/legal/terms-and-conditions/msa-service-schedules.
Billing Information
Prices shown above do not include any state and local taxes that may apply. Any such taxes
are the responsibility of the Customer and will appear on the final Invoice.
Is the contracting entity exempt from sales tax?
Please select Yes or No: Yes
If yes, please send the required tax exemption documents immediately to
taxexemot(dWocusign.com.
Invoices for this order will be emailed automatically from invoicinq(a-)-err).docusign.corT'. Please
make sure this email is on an approved setting or safe senders list so notifications do not go to
a junk folder or caught in a spam filter.
Purchase Order Information
Is a Purchase Order ("PO") required for the purchase or payment of the products on this Order
Form?
Please select: x Yes No
By marking "No", Customer agrees to process payment for any invoices issued pursuant to this
Order Form without a PO Number.
If yes, please complete the following information, and attach your PO (if available), and the
invoice will be issued referencing such PO Number:
PO Number: 20242060
Page 2 of 3
DocuSign Envelope ID: 57C6B811-6ABF-48CF-BOA1-5C19445C75E1
Please attach PO Attachment here:
If "Yes" is marked, but a PO Number is not provided or a PO document is not attached, then
Customer agrees to provide the PO information or PO document to DocuSign at its earliest
convenience by sending to POSubmission(o)docusign.com referencing this Quote Number, but
agrees to still process payment per the agreed upon terms.
If Customer has attached a PO (or other document) to this Order Form, Customer
acknowledges and agrees that any additional or conflicting terms appearing in such PO (or any
other document) are invalid.
By signing this Agreement, I certify that I am authorized to sign on behalf of the
Customer and agree to the Terms and Conditions of this Order Form and any
documents incorporated herein.
Customer DocuSigned by:
Signature: 143lF57D413554D6...
DocuSign, DocuSigned by:
Inc.
Signature:
EF06C8C5487294E5
Name: Freddy Suarez Name:
Job Title: Procurement services Director Job Title:
Date: December 22, 2023 Date:
Frank Parish
Revenue operations Manager
December 29, 2023
DS
Page 3 of 3
DocuSign Envelope ID: 57C6B811-6ABF-48CF-BOA1-5C19445C75E1
&C,
EE040
C NT
Choice of Champions
Bill To PROCUR Ship To PROCUR
PROCUREMENT SERVICES DEPT PROCUREMENT SERVICES DEPT
685 WEST MONTROSE STREET 685 WEST MONTROSE STREET
2ND FLOOR 2ND FLOOR
CLERMONT, FL 34711 CLERMONT, FL 34711
Vendor 20081
DOCUSIGN INC
221 MAIN STREET, SUITE 1550
SAN FRANCISCO, CA 94105
REM ITTANCE(dDOCUSIGN.COM
Purchase Order
Fiscal Year 2024
Page 1 of 1
- . �.
AND
CORRESPONDENCE.
Purchase Order Number
20242060
Purchase Order Date
12/22/2023
Department
PROCUREMENT
Required By
01/12/2024
Payment Terms
Net-30 Days
Tax Exempt
85-8012740096C-8
Tax ID
59-6000290
f Z111YA1.11.1
Q*3110/•11INLI
DEPARTMENT QUOTE: This purchase order is being issued, as per all terms and conditions pertaining to this purchase order, to
acquire DocuSign e-signature annual subscription as per vendor quote number Q-01377060 dated 12/19/23. Please contact the City
Representative to schedule a delivery date and submit an invoice.
City Representative: Freddy Suarez
Phone: (352) 241-7350
Email: fsuarez(a-)clermontfl.orq
1 eSignature Business Pro Edition - Envelope Subs. 1,100
Annual subscription from Jan. 13, 2024, to Jan. 12, 2025.
GL #:10000 - 15500
$924.00
GL #:10565 - 55219
$2,772.00
2 Premier Support - eSign
GL #:10000 - 15500
$138.60
GL #:10565 - 55219
$415.80
PURCHASE ORDER TERMS AND CONDITIONS ARE AVAILABLE ON:
hftps://www.clermontfl.qov/219/Policy-and-Procedures
1,100.0000 EACH
Approval Date: 12/22/2023
1.0000
EACH
$3.3600 $3,696.00
$554.4000 $554.40
Approver Name: Freddy Suarez
Procurement Services Director
Page 1 of 1