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DocuSign Envelope ID:93039227-OC40-4DA1-8CBE-17FBAOEE6AEE <br /> ORANGE COUNTY-DEPARTMENT USE ONLY <br /> Department <br /> Party/Vendor Name: ELIZABETH KRZYSZTOFORSKA Party/Vendor Contact Person: ELIZABETH <br /> KRZYSZTOFORSKA Contact Phone: 336-513-2259 Party/Vendor Address: 447 FEARRINGTON POST City <br /> PITTSBORO State: NC Zip: 27312 Department: HEALTH Amount: $35,000 Purpose: DENTAL SERVICES Budget <br /> Code(s): 10410120-630000 Vendor # 30702 (N/A if new vendor) Vendor is a BOCC consultant? Yes ❑ No[] <br /> Contract Type: (Check one)New ❑ Renewal ® Amendment ❑ Effective Date 7/1/2016 Approved by Board Yes <br /> ❑No❑ Agenda Date: <br /> This agreement is approved as to to i7icaft' "eaa�id content: <br /> ��"� 8/1/2016 <br /> Department Director's Signature C9ED9DOFC6B545E.. Date: <br /> Information Technolo0es <br /> (Applicable only to hardware/software purchases or related services)This agreement has been reviewed and is approved <br /> as to information technology content and specifications: <br /> Office of the Chief Information Officer Date: <br /> Risk Management <br /> This agreement is approved for sufficienc o 1ft �"Mtandards, specifications,and requirements: <br /> �!,DCF9176800498 USA. V'l�tkN 8/1/2016 <br /> Office of the Risk Management Officer ... Date: <br /> Financial Services <br /> This instrument has been pre-audited i t c nan$er inquired by the Local Government Budget and Fiscal Control Act: <br /> Office of the Chief Financial Officer �4 a1ACC1409... Date: 8/2/2016 <br /> Legal Services <br /> This agreement is approved as t eg�P`14§t�I'fda�hl sufficiency: <br /> � 1� 8/3/2016 <br /> Office of the County Attorney �S�RR��a�oaoo Date: <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 /> Rev. 6/16 9 <br />