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DocuSign Envelope ID: C4E78886-164A-49E2-8252-F6D46323E8CC <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: $8.000 Purpose: Reimbursement for WIC Hemoglobin Testing Budget Code(s): 10414005-443110-71403 <br /> Vendor#27898 (N/A if new vendor) Vendor is a BOCC consultant? Yes ❑No❑ Contract Type: (Check one) <br /> New❑ Renewal ® Amendment ❑ Effective Date 7/1/16 Approved by Board Yes❑No❑ Agenda Date: <br /> D c Si ned b <br /> This agreement is approved as to to mcaI Yo in Ad content: <br /> (^'u"� 7/6/2016 <br /> Department Director's Signature .'z.DOFCS8545E... Date: <br /> Information Technolo0es <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 /4t i e w Aandards, specifications,and requirements: <br /> QUSA. r,Orwc,�16 7/6/2016 <br /> Office of the Risk Management Officer ,FOCFS,�sgoo498___ 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 /> rl 7/13/2016 <br /> Office of the Chief Financial Officer 7D4ES9R1ACCIAOB__ Date: <br /> Legal Services <br /> This agreement is approved as t dftd sufficiency: <br /> Office of the County Attorney L--'�� Date: 7/13/2016 <br /> Clerk to the Board <br /> Received for record retention: <br /> All Docusign contracts must be copied to Donna Lloyd upon completion @ Dolloydkorangecount.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 /> 4 <br />