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o� <br /> Ire <br /> ORANGE COUNTY-=-DEPARTMENT USE ONLY---HARD COPY ONLY <br /> Department <br /> Party/Vendor Name : UNC Health Care System Party/Vendor Contact Person : Kathryn Grant Contact <br /> Phone : 984 - 974 - 1274 Party/Vendor Address : 211 Friday Center Drive City Chapel Hill State : NC Zip : <br /> 27217 Department : Health Amount : $ 10 , 000 Purpose : Perform tubal ligations for uninsured women Budget <br /> Code ( s) : 10414020 - 630000 - 71400 Vendor # 21680 (N/A if new vendor) Vendor is a BOCC consultant? <br /> Yes ❑ No ❑ Contract Type : (Check one) New ❑ Renewal ® Amendment ❑ Effective Date 7449 <br /> 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 pri to execution of the agreement : <br /> Department Director ' s Signature Lcs Date . III <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 sufficiency of insurance standards , specifications , and requirements . <br /> Office of the Risk Management Officer C Date . Z <br /> Financial Services <br /> This instrument has been pre - audited in the ma er required by the Local Government Budget and Fiscal Control <br /> Act : <br /> Office of the Chief Financial Officer ate : ?' ' <br /> 9 <br /> a <br /> Legal Services <br /> This agreement is approved as to legal form and sufficiency . <br /> Office of the County Attorney . ' .Xj (�1/1 UhleyiV Date : <br /> Clerk to the Board <br /> Received for record retention . <br /> All Docusign contracts must be copie She i Ingersoll upon completion : snngersoll@orangecountync . gov <br /> The following signature block is for ar c ie o a is not required for Docusign contracts : <br /> Office of the Clerk to the Board Date . <br /> Oct <br /> Revised 10/ 17 <br /> 6 � <br />