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DocuSign Envelope ID: DC123A99-06A0-46CF-848C-67887A7D9680 <br /> ORANGE COUNTY—DEPARTMENT USE ONLY <br /> Party/Vendor Name: Advanced Dental Associates, Inc. Party/Vendor Contact Person: Mindy Gill Contact Phone: <br /> 919-545-0985 Party/Vendor Address: 11312 US 15-501 North, Suite 107-139 City Chapel Hill State:NC Zip: 27517 <br /> Department: Health Amount: $2,000 Purpose: Referral of licensed dental personnel Budget Code(s): 10410120- <br /> 630000 Vendor#64922 (N/A if new vendor) Vendor is a BOCC consultant? Yes ❑No® Contract Type: (Check <br /> one)New ❑ Renewal ® Amendment ❑ Effective Date 7-1-19 Approved by Board Yes❑ No❑ Agenda <br /> Date: <br /> This agreement is approved as to technical form and content and I as Department Director affirmatively state work on <br /> this project has not been initiated prior to execution of the agreement: <br /> DocuSigned by: <br /> S&Wof 7/10/2019 <br /> Department Director's Signatur 3C18F2D09E3445F. 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 <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 sufficient DocuSigned by: rds,specifications,and requirements: <br /> aUS66 (, 6 7/10/2019 <br /> Office of the Risk Management Office El <br /> . Date: <br /> Financial Services <br /> This instrument has been pre-audited i Docusigned by: the Local Government Budget and Fiscal Control Act: <br /> '� -" 7/10/2019 <br /> Office of the Chief Financial Officer 7DaE5aa1ACC1499. Date: <br /> Legal Services <br /> This agreement is approved as t D"USigned by: <br /> '"'1` havit, T 6SL6 7/10/2019 <br /> Office of the County Attorney 079A4D525C0F4Fa. 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 12/18 4 <br />