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DocuSign Envelope ID:COB 1 73FE-65A7-41 C5-985D-8D6B23DF80FB <br /> ORANGE COUNTY—DEPARTMENT USE ONLY <br /> Party/Vendor Name: Pamela Hines Party/Vendor Contact Person: Pamela Hines Contact Phone: (336) 410-3067 <br /> Party/Vendor Address: 160 Clayton Street City Roxboro State: NC Zip: 27573 Department: Health Amount: 1560 <br /> Purpose: Clinical Supervision for Clinical Social Worker Budget Code(s): 10414020-630000-71410 Vendor # N/A <br /> (N/A if new vendor) Vendor is a BOCC consultant? Yes ❑ No® Contract Type: (Check one)New ® Renewal <br /> ❑ Amendment ❑ Effective Date 4-6-20 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 /> DocuSigned by: <br /> Department Director's Signature- S�.w�- Date: 3/30/2020 <br /> 3C16F2D09E3445F... <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 was <br /> 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 -Diocusigned by: 'ds, specifications,and requirements: <br /> �U$66 (, 6 3/30/2020 <br /> Office of the Risk Management Officer 7FDCF9176800498... Date: <br /> Financial Services <br /> This instrument has been pre-audited it DocuSigned by: the Local Government Budget and Fiscal Control Act: <br /> Office of the Chief Financial Officer ` q 4oas,acc,ao9...� Date: 3/30/2020 <br /> Legal Services <br /> This agreement is approved as tc DocuSigned by: <br /> "k �Yf, U(h 3/30/2020 <br /> Office of the County Attorney Date: <br /> 079A40525COF4FB... <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 4 <br />