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ORANGE COUNTY-DEPARTMENT USE ONLY <br /> Department <br /> Party/Vendor Name: LJNC Hospitals Party/Vendor Contact Person: Susan Blalock Contact Phone: 984-974-1155 <br /> Party/Vendor Address: 211 Friday Center Drive, Suite G021 City Chapel Hill State: NC Zip: 27517 <br /> Department: Agjqg Amount: $25,000 Purpose: Wellness Coordinator support Budget Code(s): 294303 Vendor# <br /> 30892 (N/A if new vendor) Vendor is a BOCC consultant? Yes ❑No❑ Contract Type: (Check one)New❑ <br /> Renewal ® Amendment ❑ Effective Date 07/01/2014 Approved by Board Yes❑ No❑ Agenda Date: <br /> This agreement is approved as to technical form and content: <br /> Department Director's Signature Date: X2--f <br /> 0 <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 Chief Information Officer Date: <br /> Risk Management <br /> This agreement is approved for sufficiency of insurance standards,specifications, and requireme DEC -9 2014 <br /> Office of the Risk Management Officer an_ Date: y <br /> tz1°1 y <br /> Financial Services <br /> This instrument has been pre-audited in the manner required by the Local Government Budget and Fiscal Control <br /> Act: <br /> Office of the Chief Financial Officer C'`1�V"""�w /J Date: <br /> Legal Services <br /> This agreement is approved as to legal f and su cie cy: <br /> Office of the County Attorney Date: 1 ' <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 /> Office of the Clerk to the Board Date: <br />