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ORANGE COUNTY—DEPARTMENT USE ONLY r q <br /> Department <br /> Party/Vendor Name: UNC Health Care System Party/Vendor Contact Person: Kathryn Grant Contact Phone: 984- <br /> 974-1274 Party/Vendor Address: 211 Fridgy Center Drive City Chapel Hill State: NC Zip: 27517.-Department- <br /> Health Amount: $4,000 Purpose: BCCCP Mamogram Screenings Budget Code(s): 1041 -631010 Vendor # <br /> 30892 (N/A if new vendor) Vendor is a BOCC consultant? Yes ❑ No® Contract ype: (Check one) New "/�//7 <br /> Renewal® Amendment ❑ Effective Date 7/1/17 Approved by Board Yes❑No❑ Agenda Date: 1 O fN0_2_O <br /> This agreement is approved as to technical form and content: &31 of Q <br /> Department Director's Signature Date:1�� y� r7011 r <br /> pe. /Ki►r/, <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 Lam`- 10 Date: �'/Z /7 <br /> Financial Services <br /> This instrument has been pre-audited in the er E e y the Local Government Budget and Fiscal Control Act: <br /> Office of the Chief Financial Officer Date: 2 3 <br /> 7 <br /> Legal Services <br /> This agreement is approved as to legal form and sufficiency: <br /> Office of the County Attorney i y j 1 az �d C' Date: � <br /> /�� <br /> Clerk to the Board <br /> Received for record retention: <br /> All Docusign contracts must be copied to Donna Lloyd upon completion @ Dolloydkoran ee cozen nc.gov <br /> e <br /> The following signature block is for hard copiea�nI an�s ngtt re. uired for Docusign contracts:,. ) <br /> Office of the Clerk to the Board G Date: <br /> ` �' � <br /> Revised 6/17 4 <br />