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ORANGE COUNTY-DEPARTMENT USE ONLY <br /> Department <br /> Party/Vendor Name: Saw San Mya Party/Vendor Contact Person: Contact Phone: 919-360-4309 <br /> Party/Vendor Address: 110 Fan Branch Lane City Chapel Hill State:NC Zip:27516 Department: Health Amount: <br /> Purpose: Budget Code(s): Vendor # 57752 (N/A if new vendor) Vendor is a BOCC <br /> consultant? Yes ❑ No❑ Contract Type: (Check one) New ❑ Renewal ❑ Amendment ® Effective Date <br /> 10/17/2014 Approved by Board Yes❑No❑ Agenda Date: <br /> This agreement is approved as to technic form and c to <br /> Department Director's Signature Date: 14M4 <br /> Information Technologies - <br /> (Applicable only to hardware/software purchases or related services)This agreement has been reviewed and is <br /> approved as to information technology content and specifications: <br /> Office of the Director of Information Technology Date: <br /> Risk Management <br /> This agreement is approved for sufficiency of insurance standards,specifications,and requirf(� M 2 Office of Risk Management Date: 1 s ZU14 Financial Services <br /> This instrument has been pre-audited in the manner required by the Local Government Budget and Fiscal Control <br /> Act: n� -7 <br /> Office of the Chief Financial Officer "` �" Date: I� 1 l 11 <br /> Legal Services <br /> This agreement is approved as to legal form n ufficiency: <br /> Office of the County Attorney Date: 10 —t 116r` <br /> Clerk to the Board <br /> Received for record retention: <br /> Office of the Clerk to the Board Date: <br />