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RANGE 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: Diane Shugars Party/Vendor Contact Person: Diane Shugars Contact Phone: Party/Vendor Address: 908 <br /> Higligrove Dr. City Chapel Hill State:NC Zip:27516 Department:Public Health Amount: $11,200.00 Purpose:Provider will render <br /> professional dental services at OCHD clinic Budget Code(s): 10410120-630000 Vendor#56709 (N/A if new vendor) Vendor is a <br /> BOCC consultant? Yes❑No® Contract Type:(Check one)New❑ Renewal® Amendment ❑ Effective Date July 1,2014 <br /> Approved by Board Yes❑No❑ Agenda Date:July 1 2014-June 30,2015 Title of Contract:Diane Shugars <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: 'l f <br /> I irector <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 Management <br /> Include the following coverages: ❑ CGL; ❑ Auto; ❑ WC; ❑ Professional; ❑ Property; OR No InsuranT_ Hold <br /> Contract pending receipt of Certificate of Insurance ❑. With incorporation of Insurance provisions as shown,jt~1i (orcj5s(�pi <br /> by the Risk Manager: <br /> l,lI AUG G 12014 <br /> Risk Manager's Signature: Date: <br /> 8 L zl y <br /> Financial Services <br /> This Contract is conditioned on 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 t: <br /> Financial Services Director's Si g nature: � <br /> W - %111, Date: / <br /> County Attorney <br /> Approval by Board ❑ (Contracts $90,000 0 or more for goods or services, $250,000.00 or more for construction, or any BOCC <br /> consultant contract). Approval by M ager (Most other contracts$1,000 and above). Department Director approval only❑ (Under <br /> $1,000). This contract has been revi w d and approved by the Attorney as to legal form and sufficiency: <br /> Attorney's Signature Date: z La �q- <br /> County Manager <br /> This contract has been reviewed and is approved by the County Manager Yes o❑. <br /> This contract has been reviewed and is for signature by the Chair Yes❑No❑. <br /> Manager's Signature: Date: <br /> Clerk to the B and <br /> Approved by BOCC on the—day of ,20 . S e r Chair signature on the day of 120 <br /> Clerk's Signature: Date: <br /> Revised March 2012 <br />