Orange County NC Website
Browse       Search
DocuSign Envelope ID: B78A3FOE-AA4A-4AA8-BO30-351CO676A960 <br /> ORANGE COUNTY-DEPARTMENT USE ONLY <br /> Party/Vendor Name: Triangle Urology Associates, P.A. Party/Vendor Contact Person: Pat Grinstead Contact <br /> Phone: 919-313-3662 Party/Vendor Address: 205 Frasier Street City Durham State:NC Zip: 27707 Department: <br /> Health Amount: $10,200 Purpose: Provide vasectomy services to OCHD referred males. Budget Code(s): <br /> 10414020-630000-71400 Vendor# 63847 (N/A if new vendor) Vendor is a BOCC consultant? Yes ❑ No® <br /> Contract Type: (Check one)New ❑ Renewal ® Amendment ❑ Effective Date 10-4-19 Approved by Board <br /> 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 /> DocuSigned by: <br /> S&Wof 10/4/2019 <br /> Department Director's Signature[aCisFzoosEsa45F. 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 sufficient Wcusigned by: rds,specifications,and requirements: <br /> ��tsa' ��'t'�6 10/9/2019 <br /> Office of the Risk Management Office 7MCFs176s004ss. Date: <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 /> A 10/9/2019 <br /> Office of the Chief Financial Officer 7Da�s4a1ACC1409. Date: <br /> Legal Services <br /> This agreement is approved as to Ffl <br /> DocuSigned by: {� <br /> "J, � l�S(h 10/9/2019 <br /> Office of the County Attorney_ 079MDQSCOF4FB. 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 /> Revised 12/18 <br /> 8 <br />