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ZCD1Z—!Ler/ <br /> ORANGE COUNTY—CONTRACT CONTROL SHEET <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. Cynthia Gamble PartyNendor Contact Person: Dr.Cynthia Gamble Contact Phone: Party/Vendor <br /> Address: 114 Oakmist Drive City Cary State:NC Zip: 27513 Department:Health Amount: $ Purpose: Provide Dental Services to <br /> Patients Budget Code(s): 10410020 630000 Vendor# 59544 (N/A if new vendor) Vendor is a BOCC consultant? Yes 0 Nor. <br /> Contract Type:(Check one)New 0 Renewal g Amendment n Effective Date July 1,2012 Approved by Board Yes0 No <br /> 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 /> technical content: _ <br /> Department Director's Signature: Date: 6 la I ia <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 Matjagement <br /> Include the following coverages: El CGL; 0 Auto; 0 WC; 1E- rofessional; 0 Property; 0 OR No Insurance Required 0. Hold <br /> Contract pending receipt of Certificate of Insurance 0. With incorporation of Insurance provisions as shown, this contract is approved <br /> by the Risk Manager: <br /> Risk Manager's Signature: ym t_dk, cit td.. Date: 62 •1-4?. lz-/ <br /> ro 0672/42 342/1r)%4 alb <br /> Financial Services <br /> This Contract is condition upon appropriation by the Board of Commissioners Yes0NoN. A budget amendment is necessary <br /> il <br /> before approval Yes0 N c . If budget amendment is necessary,please attach to this form. This instrument has been pre-audited in the <br /> manner required by the Loca Government Budget and Fiscal Control Act: <br /> Financial Services Director's Signature: AU-LA.- A dalitA-■ Date: 7121 17.- <br /> -----4 4.1t9 <br /> County Attorney <br /> Approval by Board 0 (Contracts over $90,000.00 for goods or services, $250,000.00 for construction, or any BOCC consultant <br /> att <br /> contract). Approval by Ma y r (All other contracts). This contract has been reviewed and approved by the Attorney as to legal <br /> /s <br /> form and sufficiency: 1 <br /> N. .. „Pr ‘ 7 1 <br /> Attorney's Signature Date: • IZ- <br /> 1 <br /> County Mana2er <br /> This contract has been reviewed and is approved by the County Manager Ye.52/-No0. <br /> This contract has been reviewed and is to be submitted for OCC consideration Yes[]NoEr <br /> Manager's Signature: Date: 7— (0 --/t/ <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 />