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DocuSign Envelope ID:97238CE2-BA88-43FC-BB15-3276F9D37D17 <br /> ORANGE COUNTY—DEPARTMENT USE ONLY <br /> Department <br /> Party/Vendor Name: Diane Shugars, DDS Party/Vendor Contact Person: Diane Shugars, DDS Contact Phone: 919- <br /> 697-9251 Party/Vendor Address: 4321 Fearrington Post City Pittsboro State: NC Zip: 27312 Department: Health <br /> Amount: $24,000 Purpose: Dental Services Budget Code(s): 10410120-630000 Vendor# 56709 (N/A if new vendor) <br /> Vendor is a BOCC consultant? Yes ❑ No® Contract Type: (Check one) New ❑ Renewal ® Amendment ❑ <br /> Effective Date 7/1/2019 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 to execution of the agreement: <br /> DaeuSigned by: <br /> ljia' S�.w� 71212 019 <br /> Department Director's Signature113C16F2D09E3445F_ 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 was <br /> addressed: <br /> Information Technologies <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 /> Office of the Chief Information Officer Date: <br /> Risk Management <br /> This agreement is approved for sufficienc oocuSigned by: rds, specifications,and requirements: <br /> aUsa �,DVIn.�,{�6 7/2/2019 <br /> Office of the Risk Management Office 7FDCF9176900498. Date: <br /> Financial Services <br /> This instrument has been pre-audited it Docusigned by: the Local Government Budget and Fiscal Control Act: <br /> Office of the Chief Financial Officer 704E51S1ACC1409. Date:7/2/2019 <br /> Legal Services <br /> This agreement is approved as t Docusigned by: {� <br /> gkAk Auvit, 7/2/2019 <br /> Office of the County Attorne 079MD525COF4Fa. 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 /> Rev. 6/19 8 <br />