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DocuSign Envelope ID:572F6418-39E1-4F6F-B960-93B2BCCA7F05 <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 7/1/2017 Approved by Board Yes No Agenda Date: <br /> This agreement is approved as to to at 'rm e 'd co,tent: <br /> LXottu1 �,l 6/29/2017 <br /> Department Director's Signature 5145A2CD945c40F... Date: <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 <br /> rn gffs"5i $_ 'staandards,specifications, and requirements: <br /> UtSi. bleu/ 7/3/2017 <br /> Office of the Risk Management Officer 7FDCF9176800498... Date: <br /> Financial Services <br /> This instrument has been pre-audited i alfORFIVNuired by the Local Government Budget and Fiscal Control Act: <br /> (71.4.,p ` mini.'`". 7/3/2017 <br /> Office of the Chief Financial Officer zD4F5181ACC1409 Date: <br /> Legal Services <br /> This agreement is approved as t e// °agcyo tle abed suffciency: <br /> "` A., f 6S0 7/3/2017 <br /> Office of the County Attorney 079A4D525C0F4FB... Date: <br /> Clerk to the Board <br /> Received for record retention: <br /> All Docusign contracts must be copied to Donna Lloyd upon completion @ Dolloyd @orangecountync.gov <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 8 <br />