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Revised 01/24 <br />10 <br />ORANGE COUNTY—INTERNAL USE ONLY <br />______________________________________________________________________________ <br />Finance Information <br />Vendor Name: Select Physical Therapy Vendor Contact Person: Amy McCartney Phone: 336-765-5664 <br />Address: 120 Charlois Blvd City Winston Salem State: NC Zip: 27103 Department: Human Resouces Amount: <br />$15,000 Purpose: POET/FIT FOR DUTY TESTING/JOB ANALYSES Budget Code(s): 10250020/63000 Vendor <br /># 65168 <br />Vendor Status with NCSOS: Vendor is a BOCC consultant: Yes No <br /> <br />Contract Details <br />Contract Type: New Amendment (Original Contract: ) (Most Recent Amendment ) <br />Effective Date End Date 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 />Department Affirmation <br /> This agreement is approved as to technical form and content and I as Department Director affirmatively state <br />work on this project has not been initiated prio r to execution of the agreement. <br /> This agreement is approved as to technical form and content. Services related to this agreement have alread y <br />begun or been completed. Description of the nature of the emergency condition that was addressed: This is a <br />contract renewal because of increased pricing. <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 <br />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 />DocuSign Envelope ID: FFA73DD9-C106-407B-89D5-4182E5B591FE <br />3/27/2024 <br />4/8/2024 <br />4/11/2024 <br />4/23/2024