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ORANGE COUNTY - DEPARTMENT USE ONLY a 01�,- 3y� <br />Department <br />Party/Vendor Name: UNC School of Dentistry Party/Vendor Contact Person: - Shayna Hill Contact Phone: 919- <br />537 -3574 Party/Vendor Address: CB #7450 City Chapel Hill State: NC Zip: 27599 Department: Health Amount: <br />$66,595 Purpose: Resident dental services Budget Code(s): 10410120- 630000 Vendor #.36302 (N /A if new <br />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 />This agreement is approved as to tec ' 1 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 <br />Risk Management <br />Date: <br />This agreement is approved for sufficiency of insurance standards, specifications, and requirements: <br />Office of the Risk Management Officer - Date: (� <br />Financial Services <br />This instrument has been pre - audited in the 7nn/required by the Local Government Budget and Fiscal Control <br />Act: <br />Office of the Chief Financial Officer <br />Legal Services <br />Date: / 0 <br />This agreement is approved as to legal form and sufficiency: <br />Office of the County Attorney i �*4&A, 43 Y& Date: S110h% <br />Clerk to the Board <br />Received for record retention: <br />All Docusign contracts must be copied to Sherri Ingersoll upon completion @ Singersollgoran eg countync.gov <br />The following signature block is for hard copies only and is not required for Docusign contracts: <br />Office of the Clerk to the Board Date: <br />Rev. 6/18 <br />