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DocuSign Envelope ID:3D2AE91 F-A053-456D-811 F-727562AB2926 <br /> ORANGE COUNTY—DEPARTMENT USE ONLY <br /> Department <br /> Party/Vendor Name: Maxim Heathcare Services Party/Vendor Contact Person: Scott Dannelley Contact Phone: <br /> 919-714-8623 Party/Vendor Address: 7227 Lee Deforest Drive City Columbia State: MD Zip: 21046 <br /> Department: Health Amount: $30,000 Purpose: Temp medical staff services Budget Code(s): 10414020-630000 <br /> Vendor#63832 (N/A if new vendor) Vendor is a BOCC consultant? Yes ❑ No® Contract Type: (Check one) <br /> New ® Renewal ❑ Amendment ❑ Effective Date 11-21-16 Approved by Board Yes❑ No❑ Agenda <br /> Date: <br /> This agreement is approved as to to /f��,afuf&W find content: <br /> 1,0� 15 i 12/1/2016 <br /> Department Director's Signature Date: <br /> 1e9E59D&FCa$545E... <br /> Information Technologies <br /> (Applicable only to hardwarelsoftware 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 sufficienc), gKwwwbbstandards,specifications, and requirements: <br /> aUS& (hnut16 12/1/2016 <br /> Office of the Risk Management Officer 7FncFanFRnn4Qs Date: <br /> Financial Services <br /> This instrument has been pre-audited in the manner required by the Local Government Budget and Fiscal Control <br /> Act: DocuSigned by: <br /> Office of the Chief Financial Officer Date: 12/1/2016 <br /> Legal Services <br /> This agreement is approved as t 4 `'Md sufficiency: <br /> I �Office of the County Attorney Date: 12/2/2016 <br /> Clerk to the Board <br /> Received for record retention: <br /> All Docusign contracts must be copied to Donna Lloyd upon completion @ Dolloydoran eg countync. og_v <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 /> Revised 1/16 <br /> 8 <br />