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beo � 1r� <br /> Ol <br /> ORANGE COUNTY-DEPARTMENT USE ONLY <br /> Department <br /> Party/Vendor Name : LTNC School of Dentistry Party/Vendor Contact Person : Jessica Hill Contact Phone : 919 - <br /> 537 - 3513 Party/Vendor Address : CB #7450 City Chapel Hill State : NC Zip : 27599 Department : Health Amount : <br /> $ 69 , 924 . 03 Purpose : Resident dental services Budget Code (s) : 10410120 -630000 Vendor # 36302 (N/A if new <br /> vendor) Vendor is a BOCC consultant? Yes ❑ No ® Contract Type : (Check one) New ❑ Renewal <br /> 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 <br /> on this project has not been initiated prior to execution of the agreement : <br /> Department Director ' s Signature (,1 /1 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 <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 /> c�- <br /> Office of the Risk Management Officer �� � Date : <br /> Financial Services <br /> This instrument has been pre - audited in the a quired by the Local Government Budget and Fiscal Control <br /> Act : <br /> Office of the Chief Financial Officer Date : Z <br /> Legal Services <br /> This agreement is approved as to legal form and sufficiency : <br /> Office of the County Attorney C,/4" [,,��/(�L%t w�7rt/y - Date : 13 i `i <br /> Clerk to the Board <br /> Received for record retention : <br /> All Docusign contracts must be copie o SherINngersoll tinot <br /> completion : smgersoll@orangecountync . gov <br /> The following signature block is for ar c i y required for Docusign contracts : <br /> Office of the Clerk to the Board Date : v 5 1 <br /> ( J'ytow, % GCS 006MG�,� Cal/ <br /> Rev . 6 19 ell <br />