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Revised 10/17 <br /> <br /> <br />5 <br /> <br />ORANGE COUNTY—DEPARTMENT USE ONLY <br /> <br />______________________________________________________________________________ <br />Department <br /> <br />Party/Vendor Name: Kevin Kirk Party/Vendor Contact Person: Kevin Kirk Contact Phone: 919-419-0171 <br />Party/Vendor Address: 5311 Beaumont Drive City Durham State: NC Zip: 27707 Department: Health Amount: $600 <br />Purpose: Group instruciton for DSME program. Budget Code(s): 10414020-630000-71405 Vendor # 34783 (N/A if <br />new vendor) Vendor is a BOCC consultant? Yes No Contract Type: (Check one) New Renewal <br />Amendment Effective Date 7-1-18 Approved by Board Yes No Agenda Date: <br /> <br />This agreement is approved as to technical form and content: <br /> <br />Department Director’s Signature ________________________________________ Date: ________ <br /> <br /> <br />Information Technologies <br /> <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 /> <br />Office of the Chief Information Officer___________________________________ Date: ________ <br /> <br /> <br />Risk Management <br /> <br />This agreement is approved for sufficiency of insurance standards, specifications, and requirements: <br /> <br />Office of the Risk Management Officer___________________________________ Date: _________ <br /> <br /> <br />Financial Services <br /> <br />This instrument has been pre-audited in the manner required by the Local Government Budget and Fiscal Control Act: <br /> <br />Office of the Chief Financial Officer ____________________________________ Date: _________ <br /> <br /> <br />Legal Services <br /> <br />This agreement is approved as to legal form and sufficiency: <br /> <br />Office of the County Attorney __________________________________________Date: ________ <br /> <br /> <br />Clerk to the Board <br /> <br />Received for record retention: <br />All Docusign contracts must be copied to Sherri Ingersoll upon completion: singersoll@orangecountync.gov <br />The following signature block is for hard copies only and is not required for Docusign contracts: <br /> <br />Office of the Clerk to the Board __________________________________________Date:_________ <br />DocuSign Envelope ID: 3659A1CF-2506-4644-9391-6538AE1E27FE <br /> <br /> <br /> <br />