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Revised 07/20 5 <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 <br />Party/Vendor Address: 202B Jay Street City Chapel Hill State: NC Zip: 27514 Department: Health Amount: $16,416 <br />Purpose: Provide dental hygienist services Budget Code(s): 10410120-630000 Vendor # N/A (N/A if new vendor) <br />Vendor is a BOCC consultant? Yes No Contract Type: (Check one) New Renewal Amendment <br />Effective Date 7-1-21 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 <br />this 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 con dition 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 <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 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 /> <br /> <br /> <br />DocuSign Envelope ID: 7C92EBC6-C659-47CF-AB66-197597C1911B <br />6/29/2021 <br />6/30/2021 <br />7/1/2021 <br />7/1/2021 <br />DocuSign Envelope ID: 8820E63B-A189-4552-96CE-F9ADBC4DF87D