R 2016-401-E Health - Diane Shugars to provide dental services

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DocuSign Envelope ID: DAAE2CBD-CD76-4858-84F5-E9B3F7DOOBBC ORANGE COUNTY-DEPARTMENT USE ONLY Department Party/Vendor Name: DIANE SHUGARS Party/Vendor Contact Person: DIANE SHUGARS Contact Phone: 919-967- 9251 Party/Vendor Address: 136 OWEN TOWNE RD City CHAPEL HILL State: NC Zip: 27516 Department: HEALTH Amount: $9.800 Purpose: DENTAL SERVICES Budget Code(s): 10410120-630000 Vendor# 56709 (N/A if new vendor) Vendor is a BOCC consultant? Yes ❑ No® Contract Type: (Check one) New ❑ Renewal Amendment ❑ Effective Date 7/1/2016 Approved by Board Yes❑Nor-1 Agenda Date: This agreement is approved as to to mca�° or"m acid content: �` 6 "� 7/23/2016 Department Director's Signature C9ED9D0FCSB545E... Date: Information Technolo0es (Applicable only to hardware/software purchases or related services)This agreement has been reviewed and is approved as to information technology content and specifications: Office of the Chief Information Officer Date: Risk Management This agreement is approved for sufficient /A4gt�' '"c'y�5t�a�ndards, specifications,and requirements: QUSA, rbrv�,c 6 7/25/2016 Office of the Risk Management Officer 7FDCF9176800498... Date: Financial Services This instrument has been pre-audited i t e°manger 964uired by the Local Government Budget and Fiscal Control Act: 7/25/2016 Office of the Chief Financial Officer Lita 4E51a1ACC1409... Date: Legal Services This agreement is approved as t 7,q'FY8M'J`Id sufficiency: 4� 7/25/2016 Office of the County Attorney 35CE8304CA4A9_ Date: Clerk to the Board Received for record retention: All Docusign contracts must be copied to Donna Lloyd upon completion @ Dolloydkorangecount.nic.gov The following signature block is for hard copies only and is not required for Docusign contracts: Office of the Clerk to the Board Date: Rev. 6/16 9