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<br />DocuSign Envelope ID: EB453E96-2633-4D28-B133-0C9F1E02F8CB <br />ORANGE COUNTYDEPARTMENT USE ONLY <br />______________________________________________________________________________ <br />Department <br /> <br />Party/Vendor Name: Rachel Sigmon Party/Vendor Contact Person: Rachel Sigmon Contact Phone: (336) 587-5155 <br />Party/Vendor Address: 4045 Cleburne Court City: Haw River State: NC Zip: 27258 Department: Health Amount: <br />$35,000 Purpose: Dental Services Budget Code(s): 10410120- 630000 Vendor # N/A (N/A if new vendor) Vendor is <br />a BOCC consultant? Yes No Contract Type: (Check one) New Renewal Amendment Effective Date <br /> <br />11/1/14 Approved by Board Yes No Agenda Date: <br />This agreement is approved as to technical form and content: <br /> ________________________________________ Date: ________ <br /> <br /> <br />Information Technologies <br />Applicable only to hardware/software purchases or related services <br />() This agreement has been reviewed and is approved <br />as to information technology content and specifications: <br />Office of the Chief Information Officer________ <br />___________________________ Date: ________ <br />Risk Management <br />This agreement is approved for sufficiency of insurance standards, specifications, and requirements: <br />Office of the Risk Management Officer <br />___________________________________ Date: _________ <br /> <br /> <br />Financial Services <br />This instrument has been pre-audited in the manner required by the Local Government Budget and Fiscal Control Act: <br />Office of the Chief Financial Officer <br /> ____________________________________ Date: _________ <br />Legal Services <br />This agreement is approved as to legal form and sufficiency: <br />Office of the County Attorney <br />__________________________________________Date: ________ <br /> <br /> <br />Clerk to the Board <br />Received for record retention: <br />All Docusign contracts must be copied to Donna Lloyd upon completion @ Dolloyd@orangecountync.gov <br />The following signature block is for hard copies only and is not required for Docusign contracts: <br /> <br />Office of the Clerk to the Board <br /> __________________________________________Date:_________ <br /> <br /> <br />8 <br />