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i. <br /> 0 - 5 <br /> ORANGE COUNTY-DEPARTMENT USE ONLY <br /> 1 a <br /> Party/Vendor Name : UNC Family Medicine Party/Vendor Contact Person : Pam Hoover Contact Phone : 984 - 974 - <br /> 4890 Party/Vendor Address : 590 Manning Drive City Chapel Hill State . NC Zip : 27599 Department : Health <br /> Amount : $ 167 ,217 . 50 Purpose : Medical Director Services for Clinic Budget Code (s) : 10414020 - 630000 - <br /> 71400 /71403 /71406/71408 /71409 /71414 /71416/71418 Vendor # 21243 (N/A if new vendor) Vendor is a BOCC <br /> consultant? Yes ❑ No ® Contract Type : (Check one) New ❑ Renewal ® Amendment ElEffective Date 7 - <br /> 149 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 prior to execution of the agreement : <br /> Department Director ' s Signature IJILn LJ Date : <br /> Agreements for emergency services or re air 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 , Date : 1 � <br /> Financial Services <br /> This instrument has been pre - audited in the er required by the Local Government Budget and Fiscal Control <br /> Act . <br /> Office of the Chief Financial Officer Date : g zI <br /> Legal Services <br /> This agreement is approved as to legal form and sufficiency . <br /> Office of the County Attorney 4 ,4 �� � !`" Date . <br /> Clerk to the Board <br /> Received for record retention : <br /> All Docusign contracts must be copie t She gersolI pon completion : singersoll@orangecountync . gov <br /> The following signature block is for ar c s a d s t equired for Docusign contracts : <br /> Office of the Clerk to th Board 6 0j!! Date : O O <br /> Revised 12/ 18 <br />