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ORANGE COUNT Y' DElPARTM ETA` T USE ONLY <br /> Party/Vendor Name : Polly T Riseling Party/Vendor Contact Person : Contact Phone : Party/Vendor <br /> Address : 815 Hi lg lway 70A E , unit 219 City Hillsborough State : NC Zip : 27278 Department : Aging Amount : <br /> $ 1000 Purpose : Senior Center Instructor Budget Code (s) : 1043012M29000 Vendor # 65927 (N/A if new vendor) <br /> Vendor is a BOCC consultant? Yes ❑ No ❑ Contract Type : (Check one) New ® Renewal ❑ Amendment ❑ <br /> Effective Date 01 /01 /2020 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 /> Department Director ' s Signature Date . /- <br /> Agreements for emergency services or air e not subject to the ove affirmation . If services related to this <br /> agreement have already begun or been ore <br /> ted please briefly describe the nature of the emergency condition that was <br /> addressed . i <br /> l <br /> Information Technologies 1 <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 aor <br /> greement is approved for sufficiency of insurance standards , specifications , and requirements . <br /> Office of the Rise Management Officer Date : i 3 2-u <br /> Mrd <br /> Services <br /> v� This instrument has been pre-audited in the m by the Local Government Budget and Fiscal Control Act : <br /> Office of the Chief Financial Officer Date : <br /> Legal Services <br /> This agreement is approved as to legal fo an suffi ' e eye <br /> Office of the County Attorney Date : ZbZl� <br /> Clerk to the Board <br /> Received for record retention : <br /> All Docusign contracts must be copied to Sherri Ingersoll upon completion : smgersoll@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 41P Date : VZO zG <br /> Revised 12/ 18 4 <br />