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DocuSign Envelope ID:440B28DD-5CC9-4584-A4BA-B6C20A397882 <br /> ORANGE COUNTY-DEPARTMENT USE ONLY <br /> Department <br /> Party/Vendor Name: Diane Shugars, DDS Party/Vendor Contact Person: Diane Shugars, DDS Contact Phone: 919- <br /> 697-9251 Party/Vendor Address: 136 Owen Towne Rd. City Chapel Hill State: NC Zip: 27516 Department: Health <br /> Amount: $9,800 Purpose: Dental Services Budget Code(s): 10410120-630000 Vendor# 56709 (N/A if new vendor) <br /> 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 tec WI' da content: <br /> V61(.0 6/29/2017 <br /> Department Director's Signature 9145A7c.no45f;4aF_ 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 n Qn s , tandards,specifications, and requirements: <br /> U.�tSA. rbIrl&t 7/3/2017 <br /> Office of the Risk Management Officer 79ncF91768004.8... Date: <br /> Financial Services <br /> This instrument has been pre-audited i e°ffi'W itlial Tquired by the Local Government Budget and Fiscal Control Act: <br /> (71 An a°9Z 7/3/2017 <br /> Office of the Chief Financial Officer zo4F5181Acc14o9 Date: <br /> Legal Services <br /> This agreement is approved as t cRiltlid d sufficiency: <br /> liu lit,t, f' S(b 7/3/2017 <br /> Office of the County Attorney., 079n4eseF4Fe... 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 />