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<br />DocuSign Envelope ID: 7E2FCEB6-65F3-4235-9029-18CCF5DB7E15 <br />ORANGE COUNTYDEPARTMENT USE ONLY <br />______________________________________________________________________________ <br />Department <br /> <br />Party/Vendor Name: Jennifer Hardison Walters Party/Vendor Contact Person: Jennifer Hardison Walters Contact <br />Phone: 919 225 0417 Party/Vendor Address: 2728 Sevier St. City Durham State: NC Zip: 27705 Department: <br />HEALTH Amount: $3,000 Purpose: Qualitative Evaluation Budget Code(s): 10410020-630000 Vendor # N/A (N/A <br />if new vendor) Vendor is a BOCC consultant? Yes No Contract Type: (Check one) New Renewal <br />Amendment Effective Date 1/7/2015 Approved by Board Yes No Agenda Date: <br /> <br />This agreement is approved as to technical form and content: <br /> <br /> ________________________________________ Date: ________ <br /> <br /> <br />Information Technologies <br /> <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 /> <br />Office of the Chief Information Officer________ <br />___________________________ Date: ________ <br /> <br /> <br />Risk Management <br /> <br />This agreement is approved for sufficiency of insurance standards, specifications, and requirements: <br /> <br />Office of the Risk Management Officer <br />___________________________________ Date: _________ <br /> <br /> <br />Financial Services <br /> <br />This instrument has been pre-audited in the manner required by the Local Government Budget and Fiscal Control Act: <br /> <br />Office of the Chief Financial Officer <br /> ____________________________________ Date: _________ <br /> <br /> <br />Legal Services <br /> <br />This agreement is approved as to legal form and sufficiency: <br /> <br />Office of the County Attorney <br />__________________________________________Date: ________ <br /> <br /> <br />Clerk to the Board <br /> <br />Received for record retention: <br />All Docusign contracts must be copied to Donna Lloyd upon completion @ Dolloyd@orangecountync.gov <br /> <br />The following signature block is for hard copies only and is not required for Docusign contracts: <br /> <br /> <br />Office of the Clerk to the Board <br /> __________________________________________Date:_________ <br /> <br /> <br />Revised 10/14 <br />4 <br /> <br />