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ORANGE COUNTY—DEPARTMENT USE ONLY <br /> Department <br /> Party/Vendor Name: UNC Department of Family Medicine Party/Vendor Contact Person: Kevin Tate <br /> Contact Phone: 919-843-6882 Party/Vendor Address: CB #7595, 590 Manning Drive City Chapel Hill <br /> State: NC Zip: 27514 Department: Department of Family Medicine ount: $25,000.00 Purpose: <br /> Health Screening and Health Coaching Budget Code(s): 10295020/72002 endor#21243 (N/A if new <br /> vendor) Vendor is a BOCC consultant? Yes ❑No X Contract Type: (Check one)New X Renewal ❑ <br /> Amendment ❑ Effective Date 5/1/2016 Approved by Board Yes❑No X Agenda Date: <br /> This agreement is approved as to technical form and content: <br /> Department Director's Signature��„�(A, �G�..t�/ Date: <br /> ,S/2,31.201 (o <br /> Information Technologies <br /> (Applicable only to hardware/sofdware purchases or related services)This agreement has been reviewed <br /> and is 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 standar s,speeci�fic-a-tiions,and requirements: <br /> Office of the Risk Management Officer Date: <br /> Financial Services <br /> This instrument has been pre-audited in the nne ire y the Local Government Budget and Fiscal <br /> Control Act: <br /> Office of the Chief Financial Officer Date: �b <br /> Legal Services <br /> This agreement is approved as tIle . a u ciency: <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 @ Dolloydkorangecountync.gov <br /> The following signature block is for hard copies only and is not required for Docusign contracts: <br />