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'7 <br /> ORANGE COUNTY—DEPARTMENT USE ONLY <br /> Department <br /> Party/Vendor Name: UNC School of Dentistry Party/Vendor Contact Person: Shama Hill Contact Phone: 919- <br /> 537-3574 Party/Vendor Address: CB#7450 City Chapel Hill State:NC Zip:27599 Department:Health Amount: <br /> $63,424 Purpose: Resident dental services Budget Code(s): 10410120-630000 Vendor # 36302 (N/A if new <br /> vendor) Vendor is a BOCC consultant? Yes ❑ No® Contract Type: (Check one) New ❑ Renewal ® ' <br /> Amendment ❑ Effective Date 7/1/17 Approved by Board Yes❑No❑ Agenda Date: <br /> This agreement is approved as to technical form and content: �r <br /> Department Director's Signature Date: D <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/offiinsurance standards,specifications,and requirements: <br /> Office of the Risk Management Officer(E - Date:_1.f/ 7� <br /> Financial Serv' <br /> This instrument has been pre-audited in the e r q fedthe Local Government Budget and Fiscal Control <br /> Act: 7 <br /> Office of the Chief Financial Officer Date: g <br /> Legal Services <br /> This agreement is approved as to legal form and sufficiency: <br /> Office of the County Attorney v�CLU. ���"� Date: <br /> Clerk to the Board <br /> Received for record retention: <br /> All Docusign contracts must be copied to Donna Lloyd upon completion @ Dolloyd@orangecogpty!!c.gov <br /> The following signature block is for hard copies only and is n required for Docusign contracts: <br /> Office of the Clerk to the Board Date: ���1 7 <br /> Rev. 6/16 <br />