R 2016-423-E Health - Jennifer Durham Crisp for dental services

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DocuSign Envelope ID:4250E623-7DB7-4E1C-AF70-8lC64E3C944F ORANGE COUNTY—DEPARTMENT USE ONLY Department Party/Vendor Name: Jennifer Durham Crisp Party/Vendor Contact Person: Jennifer Durham Crisp Contact Phone: 919- 412-3568 Party/Vendor Address: 10017 River Bank Drive City Raleigh State: NC Zip: 27614 Department: Health Amount: $9,800 Purpose: Dental Services Budget Code(s): 10410120-630000 Vendor # N/A (N/A if new vendor) Vendor is a BOCC consultant? Yes ❑ No® Contract Type: (Check one) New ® Renewal ❑ Amendment ❑ Effective Date 8/1/2016 Approved by Board Yes❑No❑ Agenda Date: This agreement is approved as to to n&F`lb?W$Yid c ntent: �� 8/3/2016 Department Director's Signature Date: Information Technologies (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 sufficiencNMf-iY PMltlb_egt'anndards,specifications, and requirements: �!Ausol (hnutl6 8/3/2016 Office of the Risk Management Officer 7FDCF9176800498... Date: Financial Services DocuSi ned b This instrument has been pre-audited i t e manner 6quired by the Local Government Budget and Fiscal Control Act: � L 8/3/2016 Office of the Chief Financial Officer 7D4E5181ACC1409... Date: Legal Services This agreement is approved as t egWf fi4fd d sufficiency: � 8/4/2016 Office of the County Attorney 4 Date: Clerk to the Board Received for record retention: All Docusign contracts must be copied to Donna Lloyd upon completion @ Dollo dkoran eg countync. oovv 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