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ORANGE COUNTY-DEPARTMENT USE ONLY <br /> Denartment <br /> Party/Vendor Name: UNC Health Care System Party/Vendor Contact Person: Kathryn Grant Contact Phone:984- <br /> 974-1274 Party/Vendor Address: 211 Friday Center Drive City Chapel Hill State:NC Zip:27217 Department: ui( <br /> Health Amount: JjQ&00 Purpose: Perform tubal ligations for uninsured women Budget Code(s): 10414020- <br /> 630000 Vendor#21680 (N/A if new vendor) Vendor is a BOCC consultant? Yes ❑ No Contract Type: <br /> (Check one)New ® Renewal ❑ Amendment ❑ Effective Date 7-1-17 Approved by Board Yes[] No[] 1 <br /> Agenda Date: <br /> This agreement is approved as to technical form and content: <br /> Department Director's Signature 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 M`nag m n <br /> This agreement is approved for sufficiency of insurance standards,,specifications,and requirements: <br /> Office of the Risk Management Officer �/�—�- ,. / / Date: � 3/( 7 <br /> This instrument has been pre-audited in the anne equired the Local Government Budget and Fiscal Control <br /> Act: ; <br /> i <br /> Office of the Chief Financial Officer Date: 'S 2 3 <br /> Legal Services <br /> This agreement is approved as to legal form and sufficiency: y <br /> Office of the County Attorney i 1z /�' -L, Date: �J a2$11 <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 co n i n equired for Docusign contracts: <br /> Office of the Clerk to the Board �-- Date: j <br /> 06VOSM160CX 61 9 <br />