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Revised 04/23 <br /> <br />ORANGE COUNTY—INTERNAL USE ONLY <br />______________________________________________________________________________ <br />Finance Information <br />Vendor Name: Shahab Siahpoosh Vendor Contact Person: Shahab Siahpoosh Phone: 252-432-2935 Address: 1520 Pebble Creek <br />Xing City Durham State: NC Zip: 27713 Department: Health Amount: $4,000 Purpose: Dental Hygienist Services Agreement <br />Budget Code(s): 10410120-630000 Vendor # 68081 <br />Vendor Status with NCSOS: Vendor is a BOCC consultant: Yes No <br /> <br />Contract Details <br />Contract Type: New Amendment (Original Contract: 2023-250-E) (Most Recent Amendment ) <br />Effective Date 8-15-23 End Date 6-30-24 Notice Date (Notice Purpose ) <br /> <br />Award <br /> Approved by Board (Agenda Date: ); Made or Administered by <br /> <br />Signature Authority <br />- BOCC Express Delegation (Agenda Date: ) <br />- Policy 9.4: Under $5,000; Service Under $90,000; Construction Under $250,000 <br />- Budget Policy Section XV (Capital Improvement Project: ) <br /> <br />Bidding <br /> Informal Bidding ($30k-$90k); Formal RFP ($90k+); Other (<$30k); Exception(# ) <br /> <br />Department Affirmation <br /> This agreement is approved as to technical form and content and I as Department Director affirmatively state work on this project <br />has not been initiated prior to execution of the agreement. <br /> Services related to this agreement have already begun or been completed. Description of the nat ure of the emergency condition that <br />was addressed: <br /> <br />Department Director’s Signature ________________________________________ Date: ________ <br /> <br />Information Technologies <br />This agreement has been reviewed and is approved as to information technology content and specifications: <br /> <br />Office of the Chief Information Officer___________________________________ Date: ________ <br /> Inapplicable because no hardware/software purchases or related services <br /> <br />Risk Management <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 />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 />This agreement is approved as to legal form and sufficiency: <br /> <br />Office of the County Attorney __________________________________________Date: ________ <br /> <br />Clerk to the Board <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 />Received for record retention: <br />Office of the Clerk to the Board __________________________________________Date:_________ <br />DocuSign Envelope ID: 95FBCF6F-BA3A-420D-A1F4-BCA41C85CAC9 <br />8/9/2023 <br />8/9/2023 <br />8/9/2023 <br />8/11/2023