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�y <br /> ORANGE COUNT'--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 /> Party/Vendor Name: Cynthia Gamble Party/Vendor Contact Person: Cynthia Gamble Contact Pho -380-1042 Party/Vendor <br /> Address: 114 Oakmist Dr City C� State:NC Zip:27513 Department: Public Health Amount 11 2 urpose:Provider will render <br /> professional dental services patient care at the OCHD clinics Budget Code(s): 10410120-63000 r#59544 (N/A if new vendor) <br /> Vendor is a BOCC consultant? Yes❑No® Contract Type: (Check one)New® Renewal❑ Amendment ❑ Effective Date July 1, <br /> 2013 Approved by Board Yes[]No[] Agenda Date: Title of Contract: Dental Service Agreement <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: Date: <br /> irector <br /> (Applicable only to hardware/software purchases or e :4.vic.:s)7 his contract has been reviewed and approved the Information <br /> Technology Director as to technical content a nformation techn wy specifications: <br /> IT Director's Signature: Date: <br /> Risk Ma a ement <br /> Include the following coverages: ❑ CGL; ❑ Auto; ❑ WC; 10 Professional; ❑ Property; OR No Insurance Required ❑. Hold <br /> Contract pending receipt of Certificate of Insurance ❑. With incorporation of Insurance provisions as shown, this contract is approved <br /> by the Risk Manager: <br /> Risk Manager's Signature: '�'�'�" '✓` Jr�' Date: <br /> Financial Services <br /> This Contract is conditioned 4on appropriation by the Board of Commissioners Yes❑Noo� A budget amendment is necessary <br /> before approval Yes❑Non. 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 scal Contro Act: � <br /> Financial Services Director's Signature: J Date: <br /> Cowity Attorney <br /> Approval by Board ❑ (Contracts $90,000 or more for goods o► services, $250,000.00 or more for construction, or any BOCC <br /> consultant contract). Approval by Manager (Most other contracts$1,000 and above). Department Director approval only ❑(Under <br /> $1,000). This contract has been iew an pproved by the Attorney as to legal form and suffic'ency: <br /> Attorney's Signature Date: <br /> County ManatYesNoEl. <br /> This contract has been reviewed and is approved by the County Manager Y <br /> This contract has been reviewed and is for signature by the Chair Yes❑No <br /> Manager's Signature: <br /> Date: <br /> Clektothe Board <br /> Approved by BOCC on the_day of ,20 . Submitted for Chair signature on the_day of 120 <br /> Clerk's Signature: __ Date: <br /> Revised March 2012 <br />