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DocuSign Envelope ID:0652E34F-D5F8-4884-8968-B1860CA82441 <br /> PHS/OCHD Memo of Agreement <br /> ORANGE COUNTY—DEPARTMENT USE ONLY <br /> Department <br /> Party/Vendor Name: Piedmont Health Services Party/Vendor Contact Person: Ashley Brewer Contact Phone: <br /> 336-570-3739 Party/Vendor Address: PO Box 17179 City Chapel Hill State:NC Zip: 27516 Department: Health <br /> Amount: $6,000 Purpose:Reimbursement for WIC Hemoglobin Testing Budget Code(s): 10414005-443110-71403 <br /> Vendor 4 27898 (N/A if new vendor) Vendor is a BOCC consultant? Yes ❑No❑ Contract Type: (Check one) <br /> New ❑ Renewal ® Amendment ❑ Effective Date 7/1/15 Approved by Board Yes❑No❑ Agenda Date: <br /> This agreement is approved as to to "d content: <br /> PM hG(� 10/7/2015 <br /> Department Director's Signature Date: <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 sufficienc qoicamtWtandards,specifications,and requirements: <br /> ausa, (hm,&b 10/19/2015 <br /> Office of the Risk Management Officer ZEDCF_q_Lzaa0DAga__ Date: <br /> Financial Services <br /> This instrument has been pre-audited in the manner required by the Local Government Budget and Fiscal Control <br /> Act: DocuSigned by: <br /> Office of the Chief Financial Officer EM4E5181ACC1409_lj Date: 10/19/2015 <br /> Legal Services <br /> This agreement is approved as to ab& mod sufficiency: <br /> Office of the County Attorneys Date: 10/23/2015 <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 /> 4 <br />