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DocuSign Envelope ID:60428CE2-9935-40E5-A253-2BFC8FE8BF27 <br /> ORANGE COUNTY—DEPARTMENT USE ONLY <br /> Department <br /> Party/Vendor Name: Ibraheem G. Ackall, DDS Party/Vendor Contact Person: 1. George Ackall, DDS Contact Phone: <br /> 719-691-1162 Party/Vendor Address: 405 Perry Creek Dr. City Chapel Hill State:NC Zip: 27514 Department: Health <br /> Amount: $4,000 Purpose: Dental Services Budget Code(s): 10410120-630000 Vendor# 65708 (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 /> OceuSigned by: <br /> �� S�_Wof 7/1/2019 <br /> Department Director's Signature 3C16F2D09E3445F. 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 oo'� cusigppned by:' ' •ds, specifications,and requirements: <br /> aUsa LQ 6 7/8/2019 <br /> Office of the Risk Management Officer Date: <br /> 7F6CF917880049,. <br /> Financial Services <br /> This instrument has been pre-audited i Docusigned by: the Local Government Budget and Fiscal Control Act: <br /> Office of the Chief Financial Officer CC 704E59S1ACC1409 Date: 7/8/2019 <br /> . <br /> Legal Services <br /> This agreement is approved as t D"uSigned by: <br /> 'WAk �t, U(h 7/8/2019 <br /> Office of the County Attorney o79A4D525COF4Fa. Datc: <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 />