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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 /> Party/Vendor Name: Interstate Outdoor Party/Vendor Contact Person: Contact Phone: 919-965-6646 Party/Vendor Address: <br /> P.O.Box 124 City Selma State:NC Zip:27576 Department: Public Health Amount: 2,350 Purpose: Provider will maintain an <br /> outdoor advertising display Budget Code(s): 1041202-680050 Vendor#62168 (N/A if new vendor) Vendor is a BOCC consultant? <br /> Yes❑No® Contract Type: (Check one)New® Renewal ❑ Amendment ❑ Effective Date August 5,2013 Approved by Board <br /> Yes❑No❑ Agenda Date: Title of Contract: Business Associate 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 /> t <br /> Department Director's Signature: Date:—//4 l <br /> i <br /> (Applicable only to hardware/software purchases or related services)This contract has been reviewed and a roved by the Infor <br /> Technology Director as to technical content and information tec.hra!_i _ <br /> IT Dir nature: Date: <br /> Risk Management <br /> Include the following coverages: ❑ CGL; ❑ Auto; ❑ WC; ❑ 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: e J.r-� 4 <br /> Risk Manager's Signature: �i�- �sv -- Date: 1 h l, 13 <br /> Io[10 <br /> Financial Services <br /> This Contract is conditioned ypon appropriation by the Board of Commissioners Yes❑No2+ ' A budget amendment is necessary <br /> before approval Yes❑ No[Z. 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 /> e: ,G c�. ✓ Date: l�' <br /> Financial Services Directors Signature: _ <br /> tot <br /> County Attorney <br /> Approval by Board ❑ (Contracts $90,00000 or more for goods or services, $250,000.00 or more for construction, or any BOCC <br /> consultant contract). Approval Manager[(Most other contracts$1,000 and above). Department Director approval only❑ (Under <br /> $1,000). This contract has be r\ iew a approved by the Attorney as to legal form and suffic'ency. <br /> Attorney's Signature Date- <br /> County 3 <br /> County Manager <br /> This contract has been reviewed and is appr ved b the County Manager Yeso❑. <br /> This contract has been reviewed d for 'g t e by Chair es❑No❑. <br /> Manager's Signature: Date: <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 March 2012 <br />