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Revised 10/17 <br />ORANGE COUNTY---DEPARTMENT USE ONLY---HARD COPY ONLY <br />______________________________________________________________________________ <br />Department <br /> <br />Party/Vendor Name: Planned Parenthood South Atlantic Party/Vendor Contact Person: Nancy Long Contact <br />Phone: 919-833-7526 x 6131 Party/Vendor Address: 100 S. Boylan Ave. City Raleigh State: NC Zip: 27603 <br />Department: Health Amount: $5,040 Purpose: Perform vasectomies for referred Orange County patients Budget <br />Code(s): 10414020-630000-71400 Vendor # N/A (N/A if new vendor) Vendor is a BOCC consultant? Yes <br />No Contract Type: (Check one) New Renewal Amendment Effective Date 10/5/18 Approved by <br />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 Risk Management_____________________________________________ 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 <br />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 /> <br />Office of the Clerk to the Board __________________________________________Date:_________ <br /> <br />DocuSign Envelope ID: 32C22978-D1B8-4515-AD1A-21853E88FAA8 <br /> <br /> <br /> <br />