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Revised 07/20 <br /> ORANGE COUNTY—DEPARTMENT USE ONLY <br />______________________________________________________________________________ <br /> <br />Party/Vendor Name: Ashley Perez Party/Vendor Contact Person: Ashley Perez Contact Phone: 704-649-7876 Party/Vendor <br />Address: 202B Jay Street. City Chapel Hill State: NC Zip: 27514 Department: Health Amount: $4000 Purpose: Dental Services <br />Budget Code(s): 10410120-630000 Vendor # 67224 (N/A if new vendor) Vendor is a BOCC consultant? Yes No Contract <br />Type: (Check one) New Renewal Amendment Effective Date 10-18-21 Approved by Board Yes No Agenda <br />Date: <br /> <br />This agreement is approved as to technical form and content and I as Department Director affirmatively state work on this project has <br />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 agreement have <br />already begun or been completed please briefly describe the nature of the emergency condition that was addressed: <br /> <br />Information Technologies <br /> <br />(Applicable only to hardware/software purchases or related services) This agreement has been reviewed and is approved as to <br />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, specifi cations, 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 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 /> <br />Office of the Clerk to the Board __________________________________________Date:_________ <br />DocuSign Envelope ID: 8820E63B-A189-4552-96CE-F9ADBC4DF87D <br />10/15/2021 <br />10/15/2021 <br />10/18/2021 <br />10/18/2021