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DocuSign Envelope ID:244FE7D5-741 E-4623-A304-FEOBF8OB4E65 <br /> ORANGE COUNTY—DEPARTMENT USE ONLY <br /> Department <br /> Party/Vendor Name: DIANE SHUGARS Party/Vendor Contact Person: DIANE SHUGARS Contact Phone: 919-967- <br /> 9251 Party/Vendor Address: 908 HIGHGROVE DR. City CHAPEL HILL State: NC Zip: 27516 Department: <br /> HEALTH Amount: $5,600 Purpose: DENTAL SERVICES Budget Code(s): 10410120-630000 Vendor 4 56709 (N/A <br /> if new vendor) Vendor is a BOCC consultant? Yes ❑ No® Contract Type: (Check one) New ❑ Renewal <br /> Amendment ❑ Effective Date 7/1/2015 Approved by Board Yes❑No❑ Agenda Date: <br /> This agreement is approved as to to 15/p'va4- nnd content: <br /> l��-�-w <br /> Department Director's Signature Date: 7/23/2015 <br /> Information Technologies <br /> (Applicable only to hardware/software 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 sufficient 4 Vstandards,specifications,and requirements: <br /> QUs& 66vvt,e 6 7/28/2015 <br /> Office of the Risk Management Officer mncpauranna p Date: <br /> Financial Services <br /> This instrument has been pre-audited i °��ri'��e�f wired by the Local Government Budget and Fiscal Control Act: <br /> �A.U�, 7/28/2015 <br /> Office of the Chief Financial Officer �B� a ® Date: <br /> Legal Services <br /> This agreement is approved as t=44Q d sufficiency: <br /> 7/28/2015 <br /> Office of the County Attorney Date: <br /> Clerk to the Board <br /> Received for record retention: <br /> All Docusign contracts must be copied to Donna Lloyd upon completion @ DolloyLyorangecou go v <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 />