R 2015-387-E Health - Elizabeth Krzysztoforska to provide dental services

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DocuSign Envelope ID:045AF678-3763-4394-A072-D12B1E113359 ORANGE COUNTY-DEPARTMENT USE ONLY Department Party/Vendor Name: ELIZABETH KRZYSZTOFORSKA Party/Vendor Contact Person: ELIZABETH KRZYSZTOFORSKA Contact Phone: 336-513-2259 Party/Vendor Address: 128 SUMMERLIN DRIVE City CHAPEL HILL State: NC Zip: 27516 Department: HEALTH Amount: $35,000 Purpose: DENTAL SERVICES Budget Code(s): 10410120-630000 Vendor 4 30702 (N/A if new vendor) Vendor is a BOCC consultant? Yes ❑ No ® Contract Type: (Check one)New ❑ Renewal ® Amendment ❑ Effective Date 7/1/2015 Approved by Board Yes❑No❑ Agenda Date: This agreement is approved as to to ' hnd content: Department Director's Signature p Date: 7/24/2015 e9EB9BOFC-6Bra4.r ... Information Technologies (Applicable only to hardware/software purchases or related services)This agreement has been reviewed and is approved as to information technology content and specifications: Office of the Chief Information Officer Date: Risk Management This agreement is approved for sufficient sm� "" :''standards,specifications,and requirements: Q�ASA. r,6vvt,e,tt0 7/24/2015 Office of the Risk Management Office ZEnrpg 7PAnnap Date: Financial Services This instrument has been pre-audited i °fl l i >��tquired by the Local Government Budget and Fiscal Control Act: �AU� �bliL 7/24/2015 Office of the Chief Financial Officer a�F?r�a�az® Date: Legal Services This agreement is approved as t RTT(N Ygdai'i'd sufficiency: Office of the County Attorney --- Date: 7/31/2015 Clerk to the Board Received for record retention: All Docusign contracts must be copied to Donna Lloyd upon completion @ DolloyLyorangecou go v The following signature block is for hard copies only and is not required for Docusign contracts: Office of the Clerk to the Board Date: Rev.7/15 8