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cc cp <br /> ORANGE COUNTY—DEPARTMENT USE ONLY qo / 50 (o <br /> Department <br /> Party/Vendor Name : LNC Health Care System Party/Vendor Contact Person : Kathryn Grant Contact Phone : 984 - <br /> 9744274 Party/Vendor Address : 211 Friday Center Drive City Chapel Hill State : NC Zip : 27517 Department . <br /> Health Amount : $ 8 , 000 Purpose : BCCCP Mamogram Screenings Budget Code (s) : 10414020 - 631010 -71401 Vendor <br /> # 30892 (N/A if new vendor) Vendor is a BOCC consultant? Yes ❑ No ® Contract Type : ( Check one) New ❑ <br /> Renewal ® 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 on <br /> this project has not been initiated prior to execution of the agreement . <br /> 0 Department Director ' s Signature Date : 31 � � <br /> Agreements for emergency services or epair 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 sufficiency of insurance standards , specifications , and requirements : <br /> Office of the Risk Management Officer _ Date . i <br /> Financial Services <br /> This instrument has been pre - audited in the er re uired by the Local Government Budget and Fiscal Control Act : <br /> I? I-W, I Cf <br /> Office of the Chief Financial Officer ate : <br /> Leal Services <br /> This agreement is approved as to legal form and sufficiency : <br /> Office of the County Attorney LA4,z &ft 6` �,� Date : S lTq <br /> Clerk to the Board <br /> Received for record retention . <br /> All Docusign contracts must be copi to She ers 11 u on completion : singersoll@orangecountync . gov <br /> The following signature block is for ar c onl a s of required for Docusign contracts : <br /> Office of the Clerk to the Board Date : b <br /> Revised 6/ 19 <br /> 4 <br />