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DocuSign Envelope ID:7612C085-C654-45EE-8C46-CB6A802CCEE7 <br /> ORANGE COUNTY—DEPARTMENT USE ONLY <br /> Department <br /> Party/Vendor Name: Ibraheem G. Ackall, DDS Party/Vendor Contact Person: 1. George Ackall, DDS Contact Phone: <br /> 719-691-1162 Party/Vendor Address: 405 Perry Creek Dr. City Chapel Hill State:NC Zip: 27514 Department: Health <br /> Amount: $4,000 Purpose: Dental Services Budget Code(s): 10410120-630000 Vendor# 65708 (N/A if new vendor) <br /> Vendor is a BOCC consultant? Yes ❑ No® Contract Type: (Check one) New ❑ Renewal ® Amendment ❑ <br /> Effective Date 7/l/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 this <br /> project has not been initiated prior to execution of the agreement: <br /> Department Director's Signature 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 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 sufficiency of insurance standards, specifications,and requirements: <br /> Office of the Risk Management Officer Date: <br /> Financial Services <br /> This instrument has been pre-audited in the manner required 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 form and sufficiency: <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 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 /> Rev. 6/19 8 <br />