HomeMy WebLinkAbout2012-165 S Health - Elizabeth Krzysztoforska for Dental Services $35,000 201Z.— 1(.75 —1/0.4.0.4...
ORANGE COUNTY—CONTRACT CONTROL SHEET Q
Routing Order: (1)Department,(2)IT,(3)Risk Management,(4)Financial Services,(5)Attorney,(6)Manager,(7)Clerk
This Document shall accompany all contracts and shall be submitted for signature in the Routing Order specified above. If the Manager
determines the contract is not appropriate for Manager approval the Manager shall submit the contract for BOCC approval. Contracts for
BOCC approval must be submitted through,and complete,the routing process prior to agenda review. Contracts for legal review should
be completed through the legal review process prior to being routed for signature.
Department
PartyNendor Name: Dr. Elizabeth Krzysztoforska PartyNendor Contact Person: Dr.Elizabeth Krzysztoforska Contact Phone:
Party/Vendor Address: 128 Summerlin Drive City Chapel Hill State:NC Zip:27516 Department: Health Amount: $ Purpose:
Provider Dental Services to Patients Budget Code(s): 10410120 630000 Vendor#30702 (N/A if new vendor) Vendor is a BOCC
consultant? Yes❑No Contract Type:(Check one)New❑ Renewal® Amendment ❑ Effective Date July 1,2012 Approved
by Board Yes❑NoZ Agenda Date: Title of Contract:
If this is a Grant Agreement,pre-application has been approved by the Board of Commissioners Yes❑No❑. If submitted for bid were
bids/RFPs received Yes❑ No❑ Bid/RFP number This contract has been reviewed and approved by the Department Director as to
technical content: _
Department Director's Signature: S 5-1e24.--- Date: 621 I g I l 9—
IT Director
(Applicable only to hardware/software purchases or related services)This contract has been reviewed and approved by the Information
Technology Director as to technical content and information technology specifications:
IT Director's Signature: Date:
Risk Man ement
Include the following coverages: ❑ CGL; ❑ Auto; ❑ WC; rofessional; ❑ Property; ❑ OR No Insurance Required O. Hold
Contract pending receipt of Certificate of Insurance O. With incorporation of Insurance provisions as shown, this contract is approved
by the Risk Manager: /_
Risk Manager's Signature: Wine- . I/a, Date: t¢ ' Z 7' 12../
3�` 4
Financial Services
This Contract is conditioned upon appropriation by the Board of Commissioners Yes❑No' . A budget amendment is necessary
before approval Yes❑NoX. If budget amendment is necessary, please attach to this form. This instrument has been pre-audited in the
manner required by the Local Government Budget and Fiscal Control Act:
Financial Services Director's Signature: ew�G"wi L 1. jiLt"-- Date: 1 f Z'I II
— . (..,l z°1
County Attorney
Approval by Board ❑ (Contracts over $90,000.00 for goods or services, $250,000.00 for construction, or any BOCC consultant
contract). Approval by Manager Filgo■ '11 ether contracts). This contract has been reviewed and approved by the Attorney as to legal
form and sufficiency: 0
Attorney's Signature Or Mil Date: 02
County Manager
•
This contract has been reviewed and is approved by the County Manager Ye N
/ o❑.
This contract has been reviewed and is to be submitted for :OCC •• ideration Yes❑No •
/ / /
Manager's Signature: I Date: --L---
•
Clerk to the Board
Approved by BOCC on the day of ,20 . Submitted for Chair signature on the day of ,20_____
Clerk's Signature: Date:_ _
Revised April 2010