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Home My WebLink About3/30/2016 ORDER ) as-A-- / -6 01- order FormHART ® intercivic- Date: 03/304:20/(00 Hart InterCivic, Inc. J/1/ , 5500 Wells Port Drive Jurisdiction: 811.4 ", Austin,Texas 78728 --_ r Phone: 1.800.223.HART(Option#3) Contact name: ZdaatekpFax: 1.800.437.3532 or 512.252.6776 / r. email:electionsupplies@hartic.com Contact email: 5herrt.,612,1161 -0410%-kir14 W(16.ty Billing: Shipping: 0 Same as Billing Address.1: Q o. 60,t.t 1UV-1 Address 1: i14 if V" SLS Address 2: Address 2: City/State/Zip: -& , 7 / )-1059 City/State/Zip: k "e `/, 14 774 q O Shipping special Phone: Ci t)6363.8115 requests: )900"....)) I/30 Hart System Version Fax: 4109)46°3 . g1 a g — ❑ 6.0 0 6.1 0 6.2.1 0 Other Requested /OCi- n( _`jdeliveydate: li;6(^O0 eSlate and eScan 0 eSlate only Special billing requests: iAre you ordering for a specific election? Customer PO# 0000/90138 I ❑ General 0 Primary 0 Special What languages do you require? ❑ English 0 Spanish Does your jurisdicition use VBOs? ❑ Yes ❑ No Part number Part name Quantity Unit price Amount . ba -5' , $ i ,t /% 1 - .hl. _. .,.—: i i,. 4'i ,, 3.00 'l 1D.. .00 Comments: ed i,„ 6:211/1.i Sub-tote /s/a.00 O C f_ VA1_ �,6 .,'a- yLicense&Support 7r- 41-4:1 �A• arid __2 .. Shipping&Handling P O. AlOtinikaAd 40.4.4T A 44;1144-I J 44.4A4...1 Grand total gri ---- Business Hours:8:00 AM to 5:00 PM(CST) CALL 1.800.223.HART (OPTION 3) OR FAX 1.800.437.3532 25 ® HART 2016 TEXAS Cities, Schools and Other Please open cartons immediately upon receipt of PV- �Da shipment and report discrepancies within 15 I n r e r C i v i 6 Entities- Election Supply Order Form working days. Contact Naqte eMail Address Order Date Customer PPe# applicable)O b*O I i Co f 3 ci Phone Ext Fax Bill To(Entity) Ship To(Entity) Mailing Address Ship to Address City Zip City Zip All information above is Required to insure Early Voting Starts Election Day proper processing of your order. Qty , ELECTION SETS for HART Voting Systems(HVS) Qty Item# Additional Election Forms Price 17ES9014 eSlate-Election Day-All Entities 170860 #1 Envelope-White $0.75 ea 17ES9017 eSlate-Early Voting-All Entities 170861 #2 Envelope-Canary $0.75 ea 17ES9015 eSlate w/Hand Count-Election Day-All Entities 170862 #3 Envelope-Pink $0.75 ea 17ES9019 eSlate w/Hand Count-Early Voting-All Entities 170868 #4 Envelope-Grey $0.75 ea 17ES9016 eScan/eSlate-Election Day-All Entities 171078 Certificate of Election $0.40 ea - 117E59018 eScan/eSlate-Early Voting-All Entities 171640 Paper Seal Election Day,for Ballot Box $0.60 ea Election Set Pricing(per Item#)for Hart Voting Systems: 172396 Application to Place Name on Ballot-CITY $0.40 ea 1-5 6-10 11 and over 172398 Application to Place Name on Ballot- $0.40 ea $46.25 ea $44.25 ea $41.25 ea WATER DISTRICT Qty . ELECTION SETS for OTHER Voting Systems Application to Place Name on Ballot- 172404 $0.40 ea 17ES9020 Generic-Election Day-All Entities SCHOOL DISTRICT 17ES9022 Generic-Early Voting-All Entities 172434 Wire Seals to Seal Machines,#'d•RED $0.50 ea 17ES9021 Generic w/Hand Count-Election Day-All Entities 50 100 300 500 5C 1+ 17ES9023 Generic wlHand Count-Early Voting-All Entities $23.50/lot $44.00/lot $123.00/lot $190.00/lot $0.35/ea Election Set Pricing(per Item#)for Other Voting Systems: 172436 Tug Tight Seals-Long,Red,#'d $0.55 ea 1-5 6-10 11 and over 172441 Distance Marker-EV&ED-Bilingual $1.30 ea $40.25 ea $38.25 ea $35.25 ea 172442 Notice of Prohibited Items $1.30 ea Qty Item# I Central Counting Station Price 172443 Photo ID Poster-11 x 17 $2.00 ea 179299 Receipt for Transfer Case(2 Part) $0.40 ea 172464 Writ of Election(Generic,Not Election Specific) $0.40 ea 179306 Central Counting Station Set(Generic) $10.00 ea 172574 Watchers Certificate $0.40 ea 17ES9007 Hart Voting System Central Count(HVS) $12.00 ea 172576 Oath of Office $0.40 ea Qty Item# Early Voting Ballot By Mail Supplies Price 173388 Register of Spoiled Ballots $0.45 ea 173703 Ballot Envelope-White $0.80 ea* 173392 Register of Official Ballots $0.45 ea 173704 Carrier Envelope-Canary $0.80 ea' 173408 Stamp Pad-Red Ink $4.70 ea 173706 Envelope to Mail Ballot-Green $0.80 ea* 173756 Tally List-Generic(1 set of 3) $1.50 ea 173707 Jacket Envelope-Goldenrod $0.80 ea" 173836 Statement of Residence Is in ea Election Set) $0.40 ea #14 Envelope to Mail Application for Ballot 50 100 300 500 1000 173709ENV by Mail-White $0.80 ea' $18.00 $31.00 $84.00 $121.00 $200.00 173710 Application-Early Voting by Mail-SPAN $0.35 ea 174140 Notice of Election(Generic)/Record Posting $0.35 ea 173711 Application-Early Voting by Mail-ENG $0.35 ea 174167 Returns Sheet $0.60 ea 179325 Envelope to Mail FPCA Ballot-White $0.80 ea* 176344 Rubber Stamp-VOTED S 2.45 ea 179327 Carrier Envelope-White $0.80 ea' 178010 Notice to Provisional Voter $0.40 ea Qty Item# Early Voting Ballot By Mail KITS 178011 Envelope Affidavit for Provisional Ballot-Green $0.80 ea' -+�� 173702 Early Voting Mail Only Kits(1 per voter) 178012 List of Voters Indicated as ID Voters $0.40 ea WO (Each Kit Contains 1 Eng&1 Span App) 178013 List of Provisional Voters $0.45 ea 1-25 26-100 101-250 251-500 501-5 000 178014 Envelope for Rejected I Accepted Affidavit $0.80 ea $2.15 ea 2.05 ea $2.00 ea $1.95 ea $1.80 ea 178017 Summary of Provisional Ballots $0.40 ea 176122 Military Early Voting Kits(1 per voter) 178018 Verification of Provisional Ballot $0.60 ea (contains all Envelopes for one FPCA voter) 178019 Provisional Stamp(Rubber) $8.80 ea '1-25 26-100 101-250 251-500 501-5.000 178020 Voter Information $0.40 ea $1.60 ea $1.40 ea $1.30 ea $1.25 ea $1.15 ea 178021 Secrecy Envelope $0.80 ea' Qty Item# Additional EARLY VOTING Supplies Price 178022 Voter Complaint Info Poster $1.30 ea 172441 Distance Markers-EV&ED-Bilingual $1.30 ea 178031 Provisional Bag-Orange(2 Tug Tight Seals) $35.40 ea (2 in each Election Set) 179000 Reconciliation Log ED/Cancelled Booth Log $0.80 ea 172444 Place of Early Voting Marker-Bilingual $1.20 ea 179003 Ballot&Seal Certificate(JBCIeSlate) $0.45 ea 173714 Combination Form-Early Voting(Votes 10) $0.65 ea 179029 Ballot&Seal Certificate(HVS) $0.45 ea (15 forms per Election Set)(Poll List,Sig Rost Aff)12/ 179311 Ballot&Seal Certificate(Generic) $0.60 ea 173717 Early Voting Ballot Box Seal-Sold'Each' $27.00/lot 179318 Statement of Oaths&Compensation $0.60 ea Minimum 100 $0.27 ea 179434 Combination Form•Election Day(votes 10) $0.65 ea 173753 Early Voting By Mail Poll List $0.60 ea (16 forms per Election Set)(Poll List,SigRost Aft)12/13 (3 in each Early Voting Election Set) 179536 I Voted'Stickers-1000 per roll $19.35 roll 173769 Early Voting Optical Scan Pencil $0.25 ea 179960 Precinct Supply Box(Empty) $15.75 ea 178015 Early Voting Security Form Provisional $0.45 ea Administrative Set-CANDIDATE 178016 Early Voting List of Provisional Voters $0.40 ea 179994 (Includes Orders and Notices) $11.00 ea 179978 Early Voting Roster $0.40 ea 179996 Administrative Set-PROPOSITION $11.00 ea (Includes Orders and Notices) `PRICE BREAKS FOR"QUANTITY"PURCHASES Qty Item# Voting Booths Price 50 100 300 500 1000 172003 Table Top Voting Booth Corrugated Cardboard $16.55 ea Lot: $37.50 $60.00 S150.00 $200.00 $300.00 172004 Standing Voting Booth Corrugated Cardboard $27.50 ea Each: $0.75 $0.60 5 0.50 $0.40 $0.30 MINIMUM ORDER OF$25.00 REQUIRED Prices are subject to change without notice. Rev 11f1912015 NOTE:Minimum$15.00 Shipping&Handling per Order ElectionSupplies@hartic.com Fax 800.437.3532 800.223.HART(4278)Opt 3