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ORANGE COUNTY-DEPARTMENT USE ONLY <br /> Department <br /> Party/Vendor Name: LTNC Hospitals Party/Vendor Contact Person: Susan Blalock Contact Phone: (984)974-1155 <br /> Party/Vendor Address: 211 Friday Center Dr., Suite G021 City Chapel Hill State: NC Zip: 27514 Department: <br /> Aging Amount: $25,000 Purpose: Wellness Program Director Support Budget Code(s): 29430305-499999 <br /> Vendor#30892 (N/A if new vendor) Vendor is a BOCC consultant? Yes❑No® Contract Type: (Check one) <br /> New ❑ Renewal ® Amendment ❑ Effective Date 07/01/2015 Approved by Board Yes❑No❑ Agenda <br /> Date: <br /> This agreement is approved as to technical form and content: <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 sufficiency of insurance standards,specifications,and requirements: <br /> Office of the Risk Management Officer �a �vI-./ P5=— Date: <br /> Financial Services <br /> This instrument has been pre-audited in the er required b the Local Government Budget and Fiscal Control <br /> Act: <br /> Office of the Chief Financial Officer Date: , <br /> Legal Services <br /> This agreement is approved as to legal nd suf c' y: <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 @ Dolloydgoran eg c�tync.gov <br /> The following signature block is for hMo ' a is not required for Docusign contracts: <br /> Office of the Clerk to the Board Date: 5 <br />