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DocuSign Envelope ID:887F5093-OA4D-497B-B4F7-702D1E76D390 <br /> ORANGE COUNTY---DEPARTMENT USE ONLY---HARD COPY ONLY <br /> Department <br /> Party/Vendor Name: University of North Carolina Hospitals Party/Vendor Contact Person: Brian Goldstein <br /> Contact Phone: Party/Vendor Address: 101 Manning Drive City Chapel Hill State: NC Zip: 27514 <br /> Department: County Manager- Criminal Justice Resource Office Amount: $120 per Referral Purpose: Substance <br /> Abuse Counseling Budget Code(s): 10212020-720133 Vendor # 620987 (N/A if new vendor) Vendor is a <br /> BOCC consultant? Yes ❑ No® Contract Type: (Check one) New ❑ Renewal ❑ Amendment ❑ Effective <br /> Date 9/1/16 Approved by Board Yes❑No® Agenda Date: <br /> This agreement is approved as to technical form and conten <br /> ocu5 igned by: <br /> Department Director's Signature 0 S Vtl7L Date: <br /> OA3E81B12B364B4... <br /> Information Technolosies <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 sufficiency of insurance standards, specifications,and requirements: <br /> Docu5igned by: <br /> Office of Risk Management Pausa, ('6 n 6 Date: <br /> 7FDCF9176800498... <br /> Financial Services <br /> This instrument has been pre-audited in the manner required by the Local Government Budget and Fiscal Control <br /> Act: <br /> DocuSigned by: <br /> Office of the Chief Financial Officer �° -� Date: <br /> 7NE5181ACC1409... <br /> Legal Services <br /> This agreement is approved as to legal form and sufficiency: <br /> uSigned by: <br /> Office of the County Attorney 5;t's f! Ain, Date: <br /> 328DC480549A4F5... <br /> Clerk to the Board <br /> Received for record retention: <br /> Office of the Clerk to the Board Date: <br /> Revised 6/16 <br />