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0201 .--7_14,5 <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 /> Party/Vendor Name: North Carolina Public Health Foundation Party/Vendor Contact Person: Elizabeth MacLachlan Contact Phone: <br /> 919-707-5237 Party/Vendor Address: 5505 Six Forks Road City Raleigh State:NC Zip: 27609 Department:Public Health Amount: <br /> $15,000 Purpose:Provider will provide Nicotine Replacement Therapy for residents of Orange County Budget Code(s): 10414020- <br /> 623000 Vendor#N/A (N/A if new vendor) Vendor is a BOCC consultant? Yes ❑No® Contract Type: (Check one)New <br /> Renewal❑ Amendment ❑ Effective Date May 1,2014 Approved by Board Yes❑No❑ Agenda Date: Title of <br /> Contract: Quitline <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 /> Cie <br /> Department Director's Signature: QNn 0 Date: <br /> (Applicable on y to a re urchases or related services)This contract has been reviewed and approved by t e n ormation <br /> Technology Director as to technical content an i hnology specifications: <br /> s �gna pre: Date: <br /> Risk Manaaement <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: <br /> Risk Manager's Signature: O Date: <br /> Financial Services <br /> This Contract is conditioned yi'pon appropriation by the Board of Commissioners Yes❑ .No A budget amendment is necessary <br /> before approval Yes❑ No 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 /> Financial Services Director's Signature: UO2�nc,,, 'CJi Date: I <br /> County Attorney <br /> Approval by Board ❑ (Contracts $90,000.00 or more for goods or services, $250,000.00 or more for construction, or any BOCC <br /> consultant contract). Approva by Ma ager (Most other contracts$1,000 and above). Department Director approval only El(Under <br /> $1,000). This contract has be n evie approved by the Attorney as to legal form and sufficiency: <br /> Attorney's Signature Date: 21 <br /> County Manaaer <br /> This contract has been reviewed and is ap roved by the County Manager Yes No❑. <br /> This contract has been reviewed an r si na e by e Chair s❑ ❑. <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 />