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ORANGE COUNTY-DEPARTMENT USE ONLY 2.0 I �y 0 n9 <br /> p <br /> Deartment I • <br /> Party/Vendor Name: UNC Health Care System Party/Vendor Contact Person: Kathryn Grant Contact Phone:984- <br /> 974-1274 Party/Vendor Address: 211 Friday Center Drive City Chapel Hill State: NC Zip: 27217 Department: <br /> Health Amount: $30,000 Purpose: Perform tubal ligations for uninsured women Budget Code(s): 10414020-J� <br /> 630000-71406 Vendor#21680 (N/A if new vendor) Vendor is a BOCC consultant? Y®s No® Contract Type: <br /> (Check one)New ® Renewal ❑ Amendment ❑ Effective Date 7-1-16 Approved by Board Yes❑ No❑ <br /> Agenda Date: <br /> This agreement is approved as to technical form and content: <br /> Department Director's Signature Date: <br /> Information Technologies <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 /> Office of the Risk Management Officer �� _ A Date:_r7//yi' <br /> Financial Services <br /> This instrument has been pre-audited in the m r re d by LGovernment Budget and Fiscal Control <br /> Act: <br /> Office of the Chief Financial Officer Date: Z t/s 7 <br /> Legal Services <br /> This agreement is approved as to legal o d Buff ie <br /> Office of the County Attorney Date: 1'7 <br /> Clerk to the Board <br /> Received for record retention: <br /> All Docusign contracts must be copied to Donna Lloyh upon completion @ DolloydP_oran ecountync.-og_v <br /> The following signature block is for hard*)16d is not required for Docusign contracts: <br /> Office of the Clerk to the Board Date:3 <br /> 1 S1 0�6OCX 61 9 <br />