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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: Advanced Dental Associates, Inc. Party/Vendor Contact Person: Mindy Gill Contact Phone: <br />919-545-0985 Party/Vendor Address: 11312 US 15-501 North, Suite 107-139 City Chapel Hill State: NC Zip: 27517 <br />Department: Health Amount: $700 Purpose: Referral of licensed dental hygienists Budget Code(s): 10410120-630000 <br />Vendor # 64922 (N/A if new vendor) Vendor is a BOCC consultant? Yes No Contract Type: (Check one) <br />New Renewal Amendment Effective Date 1/1/2018 Approved by Board Yes No Agenda Date: <br /> <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 Donna Lloyd upon completion @ Dolloyd@orangecountync.gov <br /> <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: FE073E3E-A914-41CA-9713-D88EF600F829 <br />  <br /> <br /> <br />