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DocuSign Envelope ID: 17C156AE-5EFE-4837-87B8-36CA89E13B8C <br /> ORANGE COUNTY-DEPARTMENT USE ONLY <br /> Party/Vendor Name: Brian Swift Party/Vendor Contact Person: Brian Swift Contact Phone: 919-824-0942 <br /> Party/Vendor Address: 4010 Sweeten Creek Road City Chapel Hill State: NC Zip: 27514 Department: Health <br /> Amount: $6,400 Purpose: Professional dental services Budget Code(s): 10410120-630000 Vendor# 65279 (N/A <br /> if new vendor) Vendor is a BOCC consultant? Yes ❑No® Contract Type: (Check one)New❑ Renewal <br /> Amendment ❑ Effective Date 7-1-19 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 <br /> on this project has not been initiated prior to execution of the agreement: <br /> DocuSigned by: <br /> S&Wof 6/27/2019 <br /> Department Director's Signature ac,sF2oosEsaa5F. Date: <br /> Agreements for emergency services or repair are not subject to the above affirmation. If services related to this <br /> agreement have already begun or been completed please briefly describe the nature of the emergency condition that <br /> was addressed: <br /> Information Technologies <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 /> Office of the Chief Information Officer Date: <br /> Risk Management <br /> This agreement is approved for sufficienc -docuSig/Pn�ed_ .by: rds,specifications,and requirements: <br /> ��Sa (.,oVln.��b 7/1/2019 <br /> Office of the Risk Management Officer 7FDCF917E800498. Date: <br /> Financial Services <br /> This instrument has been pre-audited in the manner required by the Local Government Budget and Fiscal Control <br /> Act: DocuSigned by: <br /> Office of the Chief Financial Officer .6 � Date: 7/2/2019 <br /> 7n4E51S1ACC1409. <br /> Legal Services <br /> This agreement is approved as t DocuSigned by: <br /> §WAk lka�Vit, I 7/2/2019 <br /> Office of the County Attorney Date: <br /> 079A4D525COF4Fg. <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 12/18 <br /> 8 <br />