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L47 <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: Elizabeth Krzysztoforska Party/Vendor Contact Person: Elizabeth Krzysztoforska Contact Phone: 336-513-2259 <br /> Party/Vendor Address: 128 Summerlin Dr. City Chapel Hill State:NC Zip:27516 Department:Public Health Amount: 35,000 <br /> Purpose: Provider will render professional dental services patient care at the OCHD clinics Budget Code(s): 10410120-630000 Vendor# <br /> 30702 (N/A if new vendor) Vendor is a BOCC consultant? Yes❑No® Contract Type: (Check one)New❑ Renewal <br /> Amendment ❑ Effective Date July 1,2014 Approved by Board Yes❑No[:] Agenda Date: Title of Contract:Elizabeth <br /> Krzysztoforska <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: p <br /> Department Director's Signature: Date: <br /> (Applicab a on a/software purchases or related services)This contract has been reviewed and approved by the Information <br /> Technology Director as to technical cone hnolo specifications: <br /> 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 U Fpn NE TA ed <br /> by the Risk Manager: <br /> Risk M�anager's Signature: G f'�G.r Date: JUL 2 9 2014 <br /> s <br /> 1I Financial Services <br /> B Y <br /> This Contract is conditioned on appropriation by the Board of Commissioners Yes❑No A ary <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 Bud et and Fiscal Control Act: <br /> j <br /> Financial Services Director's Signature: A �(�L� Date: <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). Approval b anager La(Most other contracts$1,000 and above). Department Director approval only❑ (Under <br /> $1,000). This contract has been a 'ewed approved by the Attorney as to legal form and sufficiency: <br /> Attorney's Signature Date: q 141 4' <br /> County Manager <br /> This contract has been reviewed and is approved by the County Manager Yes No[:]. <br /> This contract has been reviewed and is signature by the Chair Yes❑No❑. / <br /> Manager's Signature: Date: <br /> Clgfhk the Board <br /> Approved by BOCC on the day of 20 bm' ed for Chair signature on the day o ,20 <br /> Clerk's Signature: Date: / <br /> Revised March 2012 <br />