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ORANGE COUNTY—DEPARTMENT USE ONLY c�)V (,p I or3 <br /> Department <br /> Party/Vendor Name: University of North Carolina at Chapel Hill Party/Vendor Contact Person: Valerie Tan <br /> Contact Phone: 919-843-4828 Party/Vendor Address:Allied Health Sciences,CB 7120 City Chapel Hill State: <br /> NC Zip: 7599-7120 Department: Aging Amount: $14,000 Purpose: occupational therapy assessments Budget <br /> Code(s)• 0432020-630000 Vendor# 10419 (N/A if new vendor) Vendor is a BOCC consultant? Yes❑No❑ <br /> Contract Type: (Check one) New ❑ Renewal ® Amendment ❑ Effective Date 12/01/2014 Approved by <br /> Board Yes❑No❑ Agenda Date: <br /> This agreement is approved as to technical form and content: <br /> Department Director's Signature Date: /-.to•/{o <br /> Information Technologies <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 /> Office of the Chief Information Officer Date: <br /> Risk Management <br /> This agreement is approved for sufficiency of insurance standards,specifications,and requirements: <br /> Office of the Risk Management Officer �� � ,.f� Date: <br /> Financial Services <br /> This instrument has been pre-audited in the er aired Local Government Budget and Fiscal Control <br /> Act: <br /> Office of the Chief Financial Officer Date:Ayll L <br /> Legal Services <br /> This agreement is approved as to leg o an s ciency: <br /> Office of the County Attorney Date: 1 �� <br /> Clerk to the Board <br /> Received for record retention: <br /> All Docusign contracts must be copied to Donna Lloyd upon completion @ DolloydAorangecoojync.gov <br /> The following signature block is for hard copies only and is not required for Docusign contracts: <br />