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DocuSign Envelope ID: C8392BCC-AAA2-4C70-99A2-3BOA53622CD4 <br /> ORANGE COUNTY-DEPARTMENT USE ONLY <br /> Department <br /> Party/Vendor Name: CYNTHIA GAMBLE,DDS Party/Vendor Contact Person: CYNTHIA GAMBLE Contact Phone: <br /> 919-380-1042 Party/Vendor Address: 114 OAKMIST DR. City CARY State: NC Zip: 27513 Department: HEALTH <br /> Amount: $11.200 Purpose: DENTAL SERVICES Budget Code(s): 10410120-630000 Vendor 4 59544 (N/A if new <br /> vendor) Vendor is a BOCC consultant? Yes ❑No® Contract Type: (Check one)New ❑ Renewal ® Amendment <br /> ❑ Effective Date 7/1/2015 Approved by Board Yes❑No❑ Agenda Date: <br /> This agreement is approved as to tr�Docusigned 1%4r b,�: <br /> °Department Director's Signatur Date: 7/23/2015 <br /> � C9ED9D0FC66545E... <br /> Information Technolouies <br /> (Applicable only to ha7rdwa7re/sofhva7re purchases or related services)This agreement has been reviewed and is approved <br /> as to information technology content and specifications: <br /> Office of the Chief Information Officer Date: <br /> Risk Management <br /> This agreement is approved for sufficienc, -'W' o usigned by '- '-'ds, specifications, and requirements: <br /> Office of the Risk Management Officer (h1 6 Date: 7/23/2015 <br /> 7FDCF9176800498... <br /> Financial Services <br /> This instrument has been pre-audited i Dacusigned by: )y the Local Government Budget and Fiscal Control Act: <br /> P �6� 7/23/2015 <br /> Office of the Chief Financial Officer 282DFFC2CFA8476 Date: <br /> Leual Services <br /> This agreement is approved as t� Docusigned by: ncy: <br /> Office of the County Attorney � 35CB8'; 4CA4__ Date: 7/24/2015 <br /> 4�35C68304CA4A�... <br /> Clerk to the Board <br /> Received for record retention: <br /> All Docusign contracts must be copied to Donna Lloyd upon completion @ Dgilsr dsrrreesrunt ry <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 /> Rev. 7/15 8 <br />