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(1 <br /> ORANGE COUNTY—CONTRACT CONTROL SHEET t lite.e..0.1.441.1— <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. Diane Shugars PartyNendor Contact Person: Dr.Diane Shugars Contact Phone: PartyNendor <br /> Address: 3310 Environ Way City Chapel Hill State:NC Zip:27517 Department: Health Amount: $ Purpose: Provide Dental <br /> Services to Patients Budget Code(s): 10410120 630000 Vendor#56709 (N/A if new vendor) Vendor is a BOCC consultant? Yes El <br /> No11 Contract Type: (Check one)New 0 Renewal Eg Amendment 0 Effective Date July 1,2012 Approved by Board Yes0 No <br /> 0 Agenda Date: Title of Contract: <br /> If this is a Grant Agreement, pre-application has been approved by the Board of Commissioners Yes0 No0. If submitted for bid were <br /> bids/RFPs received Yes0 No0 Bid/RFP number This contract has been reviewed and approved by the Department Director as to <br /> - <br /> technical content: <br /> Department Director's signature: Date: (B 00)0, <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 Management <br /> Include the following coverages: 0 CGL; 0 Auto; 0 WC; g•firofessional; 0 Property; 0 OR No Insurance Required E. 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: 3 62-u <br /> a/MLA, /4-' Date: <br /> k <br /> pal <br /> er. ree 4,61.2,/,,,A_ <br /> Financial Services <br /> This Contract is conditioned upon appropriation by the Board of Commissioners Yes0Nogf. A budget amendment is necessary <br /> before approval Yes0 NoNl. 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 Co trol Act: <br /> Financial Services Director's Signature: &A-LA. 1 . 4"4"-■ Date: If 4 ( 2- <br /> ---- cz. .. L.it°1 <br /> County Attorney <br /> Approval by Board 1:1 (Contra s over $90,000.00 for goods or services, $250,000.00 for construction, or any BOCC consultant <br /> contract). Approval by Manager ,i1 (All ,a er contracts). This contract has been reviewed and approved by the Attorney as to legal <br /> form and sufficiency: <br /> Attorney's Signature f Date: 7 ,11 1 2_ <br /> County Manager <br /> This contract has been reviewed and is approved by the County Manager YesKcioE. <br /> This contract has been reviewed and is to be s bmitted for :OCC consideration Yes0NoEir." • <br /> / <br /> Manager's Signature: fl .1 410 Date:7- ib- /2-- <br /> MI <br /> r <br /> Clerk to the Board <br /> Approved by BOCC on the day of _,20 . Submitted for Chair signature on the day of <br /> , _,0 <br /> _ . <br /> Clerk's Signature: _ Date: <br /> Revised April 2010 <br />