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ORANGE COUNTY---DEPARTMENT USE ONLY---HARD COPY ONLY <br /> Department <br /> Party/Vendor Name: University of North Carolina at Chapel Hill Party/Vendor Contact Person: Kevin Castle <br /> Contact Phone: Party/Vendor Address: 3114 Bondurant Hall, CB#7120 City Chapel Hill State: NC Zip: <br /> 27599 Department:Agin Amount: $15,000 Purpose: Occupational Therapy assessments Budget Code(s)>� <br /> 10432020-630000 & 10430020-630120 Vendor# 10419 (N/A if new vendor) Vendor is a BOCC consultant? <br /> Yes ❑ No❑ Contract Type: (Check one) New ❑ Renewal ® Amendment ❑ Effective Date 12/01/16 (7 <br /> Approved by Board Yes[]No[] Agenda Date: <br /> This agreement is approved as to technical form and content: <br /> Department Director's Signature 4, 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 Risk Management /), <br /> ? _ — Date:�7 <br /> Financial Servicios <br /> This instrument has been pre-audited in the ner red y the Local Government Budget and Fiscal Control <br /> Act: <br /> Office of the Chief Financial Officer Date: <br /> Legal Services <br /> This agreement is approved as to legal form and sufficiency: <br /> Office of the County Attorney (A", Date: $ 11 <br /> Clerk to the Board <br /> Received for record retention: <br /> Office of the Clerk to the Board Date: <br /> Revised 2/17 <br />