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ORANGE COUNTY-DEPARTMENT USE ONLY <br /> Department <br /> Party/Vendor Name: UNC Department of Family Medicine Party/Vendor Contact Person: Sherry Hay Contact <br /> Phone: 984-974-4892 Party/Vendor Address: 590 Manning Drive City Chapel Hill State: NC Zip: 27599 M, <br /> Department: Health Amount: $8,148 Purpose: Community Health Grant Subcontract Budget Code(s): 10414020- �v <br /> 630000-71424 Vendor#21243 (N/A if new vendor) Vendor is a BOCC consultant? Yes❑No® Contract Type: <br /> (Check one) New ® Renewal ❑ Amendment ❑ Effective Date 9/1/17 Approved by Board Yes❑ NOD <br /> Agenda Date: t� <br /> This agreement is approved as to technical form and content: <br /> i I <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 Management <br /> This agreement is approved for sufficiency of insurance standards,specifications,and requirements: <br /> Office of the Risk Management Officer azzn= Date:_Vag// 7 <br /> in ci 1 4vides <br /> This instrument has been pre-audited in the in er uir e Local Government Budget and Fiscal Control Act: <br /> Office of the Chief Financial Officer Date:_4064 <br /> Legal Services <br /> This agreement is approved as to legal form and sufficiency: <br /> Office of the County Attorney �{ 6 r � /C.'i4_1Y Date: 1 J1,10 I1-1 <br /> Clerk to the Board <br /> Received for record retention: <br /> All Docusign contracts must be copied to Donna Lloyd upo�i'c�omplgt' n @ Dolloydkorangecountync.gov <br /> The following signature block is for hard copies only abd is not're'Lii0d,for Docusign contracts: f <br /> Office of the Clerk to the Board Date: I <br /> Revised 6/17 4 <br />