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Order Form <br /> Orange County, NC <br /> <br /> <br /> <br />Order #: Q-173591 <br />Prepared: 02/08/2022 <br />Page 5 of 5 <br />BILLING INFORMATION <br />Billing Contact: <br /> <br />Purchase Order <br />Required? <br />[ ] - No <br />[ ] - Yes <br />Billing Address: <br /> <br />PO Number: <br />If PO required <br /> <br />Billing Email: <br /> <br />Billing Phone: <br /> <br />If submitting a Purchase Order, please include the following language: <br />The pricing, terms, and conditions of quote Q-173591 dated 02/08/2022 are incorporated into this Purchase <br />Order by reference and shall take precedence over any terms and conditions included in this Purchase Order. <br /> <br />AGREEMENT AND ACCEPTANCE <br />By signing this document, the undersigned certifies they have authority to enter the agreement. The <br />undersigned also understands the services and terms. <br /> <br /> <br />Orange County NC <br />Signature: <br /> <br /> <br /> <br />Name: <br /> <br />Title: <br /> <br />Date: <br /> <br /> <br /> <br /> <br />DocuSign Envelope ID: F5021214-1018-4541-A333-639E32F7284A