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201Z.— 1(.75 —1/0.4.0.4... <br /> ORANGE COUNTY—CONTRACT CONTROL SHEET Q <br /> Routing Order: (1)Department,(2)IT,(3)Risk Management,(4)Financial Services,(5)Attorney,(6)Manager,(7)Clerk <br /> This Document shall accompany all contracts and shall be submitted for signature in the Routing Order specified above. If the Manager <br /> determines the contract is not appropriate for Manager approval the Manager shall submit the contract for BOCC approval. Contracts for <br /> BOCC approval must be submitted through,and complete,the routing process prior to agenda review. Contracts for legal review should <br /> be completed through the legal review process prior to being routed for signature. <br /> Department <br /> PartyNendor Name: Dr. Elizabeth Krzysztoforska PartyNendor Contact Person: Dr.Elizabeth Krzysztoforska Contact Phone: <br /> Party/Vendor Address: 128 Summerlin Drive City Chapel Hill State:NC Zip:27516 Department: Health Amount: $ Purpose: <br /> Provider Dental Services to Patients Budget Code(s): 10410120 630000 Vendor#30702 (N/A if new vendor) Vendor is a BOCC <br /> consultant? Yes❑No Contract Type:(Check one)New❑ Renewal® Amendment ❑ Effective Date July 1,2012 Approved <br /> by Board Yes❑NoZ Agenda Date: Title of Contract: <br /> If this is a Grant Agreement,pre-application has been approved by the Board of Commissioners Yes❑No❑. If submitted for bid were <br /> bids/RFPs received Yes❑ No❑ Bid/RFP number This contract has been reviewed and approved by the Department Director as to <br /> technical content: _ <br /> Department Director's Signature: S 5-1e24.--- Date: 621 I g I l 9— <br /> IT Director <br /> (Applicable only to hardware/software purchases or related services)This contract has been reviewed and approved by the Information <br /> Technology Director as to technical content and information technology specifications: <br /> IT Director's Signature: Date: <br /> Risk Man ement <br /> Include the following coverages: ❑ CGL; ❑ Auto; ❑ WC; rofessional; ❑ Property; ❑ OR No Insurance Required O. Hold <br /> Contract pending receipt of Certificate of Insurance O. With incorporation of Insurance provisions as shown, this contract is approved <br /> by the Risk Manager: /_ <br /> Risk Manager's Signature: Wine- . I/a, Date: t¢ ' Z 7' 12../ <br /> 3�` 4 <br /> Financial Services <br /> This Contract is conditioned upon appropriation by the Board of Commissioners Yes❑No' . A budget amendment is necessary <br /> before approval Yes❑NoX. If budget amendment is necessary, please attach to this form. This instrument has been pre-audited in the <br /> manner required by the Local Government Budget and Fiscal Control Act: <br /> Financial Services Director's Signature: ew�G"wi L 1. jiLt"-- Date: 1 f Z'I II <br /> — . (..,l z°1 <br /> County Attorney <br /> Approval by Board ❑ (Contracts over $90,000.00 for goods or services, $250,000.00 for construction, or any BOCC consultant <br /> contract). Approval by Manager Filgo■ '11 ether contracts). This contract has been reviewed and approved by the Attorney as to legal <br /> form and sufficiency: 0 <br /> Attorney's Signature Or Mil Date: 02 <br /> County Manager <br /> • <br /> This contract has been reviewed and is approved by the County Manager Ye N <br /> / o❑. <br /> This contract has been reviewed and is to be submitted for :OCC •• ideration Yes❑No • <br /> / / / <br /> Manager's Signature: I Date: --L--- <br /> • <br /> Clerk to the Board <br /> Approved by BOCC on the day of ,20 . Submitted for Chair signature on the day of ,20_____ <br /> Clerk's Signature: Date:_ _ <br /> Revised April 2010 <br />