Orange County NC Website
Browse       Search
DocuSign Envelope ID:735140D6-2B85-43FF-94B7-35990505652C <br /> PHS/OCHD Memo of Agreement <br /> ORANGE COUNTY-DEPARTMENT USE ONLY <br /> Department <br /> Party/Vendor Name: Piedmont Health Services Party/Vendor Contact Person: Ashley Brewer Contact Phone: <br /> 336-382-0242 Party/Vendor Address: 127 Kingston Drive City Chapel Hill State: NC Zip: 27514 Department: <br /> Health Amount: $3,000 Purpose: Reimbursement for WIC Hemoglobin Testing Budget Code(s): 10414001- <br /> 476020-71403 Vendor# 27898 (N/A if new vendor) Vendor is a BOCC consultant? Yes ❑ No❑ Contract <br /> Type: (Check one)New❑ Renewal ® Amendment ❑ Effective Date 7/1/19 Approved by Board Yes❑No <br /> ❑ 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 /> DocuSigned by: <br /> S&Wof 8/6/2019 <br /> Department Director's Signature 3C18F2809E344IF. 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 sufficienc, IDocusigned by:' 'ds, specifications,and requirements: <br /> aUSA c4Wt&6 8/6/2019 <br /> Office of the Risk Management Officer Date: <br /> 7FDCF0176800408. <br /> Financial Services <br /> This instrument has been pre-audited in the manner required by the Local Government Budget and Fiscal Control <br /> Act: DocuSigned by: <br /> Office of the Chief Financial Officer A Date: 8/7/2019 <br /> 784E51S1ACC1409. <br /> Legal Services <br /> This agreement is approved as t D"USigned by: <br /> FflWAk fta�Vit, 1 8/7/2019 <br /> Office of the County Attorney 079MD525COF4FB. 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 /> 5 <br />