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DocuSign Envelope ID: 58340D10-53F7-460D-9D47-DA2ED9BEB980 <br /> ORANGE COUNTY-DEPARTMENT USE ONLY <br /> Department <br /> Party/Vendor Name: Triangle Urology Associates, P.A. Party/Vendor Contact Person: Pat Grinstead Contact Phone: <br /> 919-313-3662 Party/Vendor Address: 205 Frasier Street City Durham State: NC Zip: 27704 Department: Health <br /> Amount: $8.000 Purpose: Provide vasectomy services to OCHD referred mailes. Budget Code(s): 10414020-630000 <br /> Vendor# 63847 (N/A if new vendor) Vendor is a BOCC consultant? Yes ❑ No® Contract Type: (Check one) <br /> New ® Renewal ❑ Amendment ❑ Effective Date 7/1/16 Approved by Board Yes❑ No❑ Agenda Date: <br /> This agreement is approved as to to ftlufi"9t1 l%.d content: <br /> 6/15/2016 <br /> Department Director's Signature Date: <br /> Information Technolosies <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 d UMstandards, specifications,and requirements: <br /> ausa, r,6rin,c,�16 6/15/2016 <br /> Office of the Risk Management Officer FBSF�z&9eeaN Date: <br /> Financial Services <br /> This instrument has been pre-audited i Dlga*i or-quired by the Local Government Budget and Fiscal Control Act: <br /> Office of the Chief Financial Officer Lita Date: 6/22/2016 <br /> Legal Services <br /> This agreement is approved as t RT�RffdaWd sufficiency: <br /> Office of the County Attorney Date: 6/23/2016 <br /> Clerk to the Board <br /> Received for record retention: <br /> All Docusign contracts must be copied to Donna Lloyd upon completion @ Dolloy(d c�orangecount.nic.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 6/16 5 <br />