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DocuSign Envelope ID:5ED77415-392C-4A8D-9E51-CB251ABA325A <br /> ORANGE COUNTY—DEPARTMENT USE ONLY <br /> Party/Vendor Name: Advanced Dental Associates, Inc. Party/Vendor Contact Person: Minder Contact Phone: <br /> 919-545-0985 Party/Vendor Address: 11312 US 15-501 North, Suite 107-139 City Chapel Hill State:NC Zip: 27517 <br /> Department: Health Amount: $2,000 Purpose: Referral of licensed dental personnel Budget Code(s): 10410120- <br /> 630000 Vendor#64922 (N/A if new vendor) Vendor is a BOCC consultant? Yes ❑No® Contract Type: (Check <br /> one)New ❑ Renewal ® Amendment ❑ Effective Date 5/10/21 Approved by Board Yes❑ No❑ Agenda <br /> 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 p ' T*0Ctfl n of the agreement: <br /> .4a" S&Walrf 5/6/2021 <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 <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 sufficiency iraswgaea,,standards,specifications,and requirements: <br /> gusa, (hmt& 5/6/2021 <br /> Office of the Risk Management Officer Date: <br /> EF9176806498... <br /> Financial Services <br /> This instrument has been pre-audited i 9MWP&ePftquired by the Local Government Budget and Fiscal Control Act: <br /> O . 5/10/2021 <br /> Office of the Chief Financial Officer S. 7 Date: <br /> Legal Services <br /> This agreement is approved as t 4i,PfildAffd sufficiency: <br /> akk , L T Mb 5/10/2021 <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 /> Revised 07/20 4 <br />