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DocuSign Envelope ID: EAA6285F-8A68-4540-94FF-6DOOBC770228 <br /> ORANGE COUNTY-DEPARTMENT USE ONLY <br /> Department <br /> Party/Vendor Name: Diane Shugars, DDS Party/Vendor Contact Person: Diane Shugars, DDS Contact Phone: 919- <br /> 697-9251 Party/Vendor Address: 4321 Fearrington Post City Pittsboro State: NC Zip: 27312 Department: Health <br /> Amount: $7,200 Purpose: Dental Services Budget Code(s): 10410120-630000 Vendor# 56709 (N/A if new vendor) <br /> Vendor is a BOCC consultant? Yes ❑ No® Contract Type: (Check one) New ❑ Renewal ® Amendment ❑ <br /> Effective Date 5/l/2021 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 this <br /> project has not been initiated prior to execution of the agreement: <br /> DocuSigned by: 1L. ���_'1 <br /> Department Director's Signature �t1vUA�l.A Slwa�'1 Date: 4/6/2021 <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 approved <br /> 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 4 ¢aystandards,specifications,and requirements: <br /> !USA, rb MA6 4/12/2021 <br /> Office of the Risk Management OfficerLzrncr91z6;ton4QADate: <br /> Financial Services <br /> This instrument has been pre-audited if1hzPfff&Wf iMquired by the Local Government Budget and Fiscal Control Act: <br /> L!�j04/14/2021 <br /> Office of the Chief Financial Officer Date: <br /> Legal Services <br /> This agreement is approved as t 'f&ffldSffd sufficiency: <br /> Ql A&I, t, �S(h 4/14/2021 <br /> Office of the County Attorney Date: <br /> Clerk to the Board <br /> Received for record retention: <br /> All Docusign contracts must be copied to the Clerk upon completion: occlerkdocs@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 /> Rev.4/21 8 <br />