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DocuSign Envelope ID:442C35DB-8F7E-464D-90B8-19DA4AF12B4F <br /> ORANGE COUNTY-DEPARTMENT USE ONLY <br /> i <br /> Department <br /> Party/Vendor Name: Janet Whitesides R.N. Party/Vendor Contact Person: Contact Phone: <br /> Party/Vendor Address: 107 Center St City Carrboro State: NC Zip: 27510 Department: Aging Amount: $5,000.00 <br /> Purpose: wellness instructor Budget Code(s): 29430320-622000 Vendor#62174 (N/A if new vendor) Vendor is a <br /> BOCC consultant? Yes ❑No❑ Contract Type: (Check one)New❑ Renewal ® Amendment ❑ Effective Date <br /> November 21,2015 Approved by Board Yes❑No❑ Agenda Date: <br /> This agreement is approved as to technical form and content: <br /> DocuSigned by: <br /> Department Director's Signature 11f 1- fi Date: 11/19/2015 <br /> i <br /> B7E9=1 BF454FA. <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 /> i <br /> Office of the Chief Information Officer Date: <br /> Risk Management <br /> This agreement is approved for sufficiency of insurance standards,specifications,and requirements: <br /> P DocuSigned"by:'USA. r,6vvt,e 6 11/19/2015 <br /> Office of the Risk Management Officer Date: <br /> 7FDCF9176800498... <br /> Financial Services f <br /> This instrument has been pre-audited in the WaTe Nr Aired by the Local Government Budget and Fiscal Control Act: <br /> S <br /> Office of the Chief Financial Officer <br /> ( '�°' '� Date: 11/20/2015 <br /> 7D4E5181ACC1409... <br /> 4 <br /> t <br /> Leizal Services <br /> This agreement is approved as to legal forrm and sufficiency: <br /> 11/20/2015 <br /> Office of the County Attorney Date: <br /> 4035CB8304CA4A9... <br /> Cleric to the Board <br /> Received for record retention: <br /> All Docusign contracts must be copied to Donna Lloyd upon completion @ Dolloyd@orangecoupVnc.gov <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 /> Revised 10/14 4 <br /> i <br /> i <br />