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DocuSign Envelope ID:AF952183-DCC6-47F3-9841-1B9C7887DC3D <br /> ORANGE COUNTY—DEPARTMENT USE ONLY <br /> Department <br /> Party/Vendor Name: Brian Swift Party/Vendor Contact Person: Brian Swift Contact Phone: 919-824-0942 Party/Vendor <br /> Address: 4010 Sweeten Creek Road City Chapel Hill State:NC Zip: 27514 Department: Health Amount: $2,400 Purpose: <br /> Professional dental services Budget Code(s): 10410120-630000 Vendor#65279 (N/A if new vendor) Vendor is a BOCC <br /> consultant? Yes ❑ No® Contract Type: (Check one) New ❑ Renewal ❑ Amendment ® Effective Date 2-18-19 <br /> Approved by Board Yes❑No❑ Agenda Date: <br /> This agreement is approved as to technical form and content and I as Department Director affirmatively state work on this <br /> project has not been initiated prior t 11 :the agreement: <br /> avUA" S&Wavl 2/14/2019 <br /> Department Director's Signature Date: <br /> Agreements for emergency services or repair are not subject to the above affirmation. If services related to this agreement have <br /> already begun or been completed please briefly describe the nature of the emergency condition that was addressed: <br /> Information Technologies <br /> (Applicable only to hardware/software purchases or related services)This agreement has been reviewed and is approved as to <br /> information technology content and specifications: <br /> Office of the Chief Information Officer Date: <br /> Risk Management <br /> This agreement is approved for sufficienc nataawstandards, specifications,and requirements: <br /> QUS& CbV'�t,t b 2/15/2019 <br /> Office of the Risk Management Officer �FB6F9�76800498... Date: <br /> Financial Services <br /> This instrument has been pre-audited i ja&W quired by the Local Government Budget and Fiscal Control Act: <br /> Office of the Chief Financial Officer +�.� Date: 2/18/2019 <br /> tC•p ro,'-A8C1109... <br /> Legal Services <br /> This agreement is approved as t rid sufficiency: <br /> al�tl�l�, Auk, T�S(A 2/18/2019 <br /> Office of the County Attorne Date: <br /> Clerk to the Board <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 /> Office of the Clerk to the Board Date: <br /> Revised Dec 2018 <br />