R 2013-255 Health - Elizabeth Krzysztoforska for Professional Dental Services patient care at the OCHD clinics $35,000

Browse Search

ORANGE COUNTY-CONTRACT CONTROL SHEET Routing Order: (1)Department,(2)IT, (3)Risk Management, (4)Financial Services,(5)Attorney,(6)Manager,(7)Clerk This Document shall accompany all contracts and shall be submitted for signature in the Routing Order specified above. If the Manager determines the contract is not appropriate for Manager approval the Manager shall submit the contract for BOCC approval. Contracts for BOCC approval must be submitted through,and complete,the routing process prior to agenda review. Contracts for legal review should be completed through the legal review process prior to being routed for signature. Department Party/Vendor Name: Elizabeth Krzvsztoforska Party/Vendor Contact Person: Elizabeth Krzysztoforska Contact Phone: 919-929- Party/Vendor Address: 128 Summerlin Dr. City Chapel Hill State:NC Zip:27516 Department: Public Health Amount: - 0 Purpose: Will render professional dental services patient care at the OCHD clinics Budget Code(s): 10414020-630000 n #3e02 (N/A if new vendor) Vendor is a BOCC consultant? Yes ❑No® Contract Type: (Check one)New® Renewal A ment ❑ Effective Date July 1,2013 Approved by Board Yes❑No❑ Agenda Date: Title of Contract: Elizabeth Krzysztoforska If this is a Grant Agreement, pre-application has been approved by the Board of Commissioners Yes❑No❑. If submitted for bid were bids/RFPs received Yes❑No❑ Bid/RFP number This contract has been reviewed and approved by the Department Director as to technical content: Department Director's Signature: l% Date: IT Director (Applicable only to hardware/software purchases or related services)This contract has been reviewed and approved by the Information Technology Director as to technical content and information technology specifications: IT Director's Signature: Date: Risk Mana2ement Include the following coverages: ❑ CGL; ❑ Auto; ❑ WC; Professional; ❑ Property; OR No Insurance Required ❑. Hold Contract pending receipt of Certificate of Insurance ❑. With incorporation of Insurance provisions as shown,this contract is approved by the Risk Manager: //yy .. Risk Manager's Signature: WW1. _ Date: r/11 4 13 Financial Services This Contract is conditioned on appropriation by the Board of Commissioners Yes❑No A budget amendment is necessary before approval Yes❑No[MIf budget amendment is necessary, please attach to this form. This instrument has been pre-audited in the manner required by the Local Government Budget and Fiscal Control ct:AAtA---g Financial Services Director's Signature: &1W ,/ Date: County Attorney Approval by Board ❑ (Contracts $90,000.00 or more for goods or services, $250,000.00 or more for construction, or any BOCC consultant contract). Appro by Manager (Most other contracts$1,000 and above). Department Director approval only ❑ (Under $1,000). This contract has e revi e d' proved by the Attorney as to legal form and suffi ienc Attorney's Signature Date: Cp Cuunt1,Manager This contract has been reviewed and is approved by the County Manager Y�o❑. This contract has been reviewed and is fn ur by the hair Yes❑No�]�_ Manager's Signature: Date: `—" -Clerk to the Board Approved by BOCC on the_day of 20 . Submitted for Chair signature on the_day of 20 Clerk's Signature: Date: Revised March 2012