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Rev. 6/19 8 <br /> <br />ORANGE COUNTY—DEPARTMENT USE ONLY <br />______________________________________________________________________________ <br />Department <br /> <br />Party/Vendor Name: Ibraheem G. Ackall, DDS Party/Vendor Contact Person: I. 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: $8,000 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 7/1/2021 Approved by Board Yes No Agenda Date: <br /> <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 /> <br /> <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 /> <br />Information Technologies <br /> <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 /> <br />Office of the Chief Information Officer___________________________________ Date: ________ <br /> <br />Risk Management <br /> <br />This agreement is approved for sufficiency of insurance standards, specifications, and requirements: <br /> <br />Office of the Risk Management Officer___________________________________ Date: _________ <br /> <br />Financial Services <br /> <br />This instrument has been pre-audited in the manner required by the Local Government Budget and Fiscal Control Act: <br /> <br />Office of the Chief Financial Officer ____________________________________ Date: _________ <br /> <br />Legal Services <br /> <br />This agreement is approved as to legal form and sufficiency: <br /> <br />Office of the County Attorney __________________________________________Date: ________ <br /> <br /> <br />Clerk to the Board <br /> <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 /> <br />Office of the Clerk to the Board __________________________________________Date:_________ <br /> <br /> <br />DocuSign Envelope ID: D4681637-BD4D-4B56-88F1-150292E54C5F <br />7/6/2021 <br />7/7/2021 <br />7/8/2021 <br />7/8/2021