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DocuSign Envelope ID:52078629-O005-490E-B927-912B1A72FEB1 <br /> ORANGE COUNTY—DEPARTMENT USE ONLY <br /> Department <br /> Party/Vendor Name: CYNTHIA GAMBLE,DDS Party/Vendor Contact Person: CYNTHIA GAMBLE Contact Phone: <br /> 919-380-1042 Party/Vendor Address: 114 OAKMIST DR. City CARY State: NC Zip: 27513 Department: HEALTH <br /> Amount: $5,600 Purpose: DENTAL SERVICES Budget Code(s): 10410120-630000 Vendor # 59544 (N/A if new <br /> vendor) Vendor is a BOCC consultant? Yes ❑No® Contract Type: (Check one)New❑ Renewal® Amendment <br /> ❑ Effective Date 7/1/2016 Approved by Board Yes❑No❑ Agenda Date: <br /> This agreement is approved as to tec n Mc"flgdA�,d'ryc ntent: <br /> Iv` 9/26/2016 <br /> Department Director's Signature Date:F it <br /> Information Technologies <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 l'l_�'s'tllandards,specifications, and requirements: <br /> aLtSA. bvvutl6 9/26/2016 <br /> Office of the Risk Management Officer 7FDCF9176800498... Date: <br /> Financial Services <br /> This instrument has been pre-audited i e fVAMV Ytquired by the Local Government Budget and Fiscal Control Act: <br /> �� 10/3/2016 <br /> Office of the Chief Financial Officer Date: <br /> Legal Services <br /> This agreement is approved as t egRPT1W 7h i sufficiency: <br /> �� <br /> Office of the County Attorney -� Date: 10/4/2016 <br /> Clerk to the Board <br /> Received for record retention: <br /> All Docusign contracts must be copied to Donna Lloyd upon completion @ Dollo dkoran eg countync. oovv <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 g <br />