Orange County NC Website
Revised 12/18 <br />ORANGE COUNTY—DEPARTMENT USE ONLY <br />______________________________________________________________________________ <br /> <br />Party/Vendor Name: UNC Family Medicine Party/Vendor Contact Person: Pam Hoover Contact Phone: 984-974- <br />4890 Party/Vendor Address: 590 Manning Drive City Chapel Hill State: NC Zip: 27599 Department: Health <br />Amount: $167,217.50 Purpose: Medical Director Services for Clinic Budget Code(s): 10414020-630000- <br />71400/71403/71406/71408/71409/71414/71416/71418 Vendor # 21243 (N/A if new vendor) Vendor is a BOCC <br />consultant? Yes No Contract Type: (Check one) New Renewal Amendment Effective Date 7- <br />1-20 Approved by Board Yes No Agenda Date: 6-18-20 <br /> <br />This agreement is approved as to technical form and content and I as Department Director affirmatively state work <br />on this project has not been initiated prior to exec ution 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 <br />was addressed: <br /> <br />Information Technologies <br /> <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 /> <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 <br />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 />DocuSign Envelope ID: 35CF0D44-9F21-47B7-A1C3-309059023B95 <br />8/4/2020 <br />8/5/2020 <br />8/5/2020 <br />8/5/2020