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Rev. 7/15 8 <br /> <br />ORANGE COUNTY—DEPARTMENT USE ONLY <br />______________________________________________________________________________ <br />Department <br /> <br />Party/Vendor Name: ELIZABETH KRZYSZTOFORSKA Party/Vendor Contact Person: ELIZABETH <br />KRZYSZTOFORSKA Contact Phone: 336-513-2259 Party/Vendor Address: 128 SUMMERLIN DRIVE City <br />CHAPEL HILL State: NC Zip: 27516 Department: HEALTH Amount: $35,000 Purpose: DENTAL SERVICES <br />Budget Code(s): 10410120-630000 Vendor # 30702 (N/A if new vendor) Vendor is a BOCC consultant? Yes No <br /> Contract Type: (Check one) New Renewal Amendment Effective Date 7/1/2015 Approved by Board <br />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 approved <br />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 /> <br /> <br />DocuSign Envelope ID: 045AF678-3763-4394-A072-D12B1E113359 <br /><br />  <br /><br />  <br /><br />  <br /><br />