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DocuSign Envelope ID:COE92964-1 D40-431E-B3C2-48EE5F39527D <br /> ORANGE COUNTY—DEPARTMENT USE ONLY <br /> Department <br /> Party/Vendor Name: Triangle Urology Associates, P.A. Party/Vendor Contact Person: Pat Grinstead Contact Phone: 919- <br /> 313-3662 Party/Vendor Address: 205 Frasier Street City Durham State: NC Zip: 27707 Department: Health Amount: <br /> 4 800 Purpose: Provide vasectomy services to OCHD referred males Budget Code(s): 10414020-630000-71400 Vendor# <br /> 63847 (N/A if new vendor) Vendor is a BOCC consultant? Yes ❑ No® Contract Type: (Check one)New ❑ Renewal <br /> ❑ Amendment ® Effective Date 4-24-19 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 /> projehas not been initiated prior t^^�^^ *^^ ^F*',^ <br /> ct P Oceusigned by:nedb� S�_Wo 4/29/2019 <br /> Department Director's Signature Date: <br /> 3C16F2D09E3445F. <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 sufficient '-oocusigned by:' ' ds, specifications,and requirements: <br /> USa (,4V1rt,t,�6 4/29/2019 <br /> Office of the Risk Management Officer[, Date: <br /> 7F6CF917E800498. <br /> Financial Services <br /> This instrument has been pre-audited it ^pocusigned by "—the Local Government Budget and Fiscal Control Act: <br /> Office of the Chief Financial Officer 4 Date: 5/1/2019 <br /> 7NE5181ACC1409. <br /> Legal Services <br /> This agreement is approved as to' <br /> g PP Docusigned by: <br /> Office of the County Attorney IKAZ AkaYit, TM(h Date: 5/1/2019 <br /> 079A40525C0F4FB. <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 />