HomeMy WebLinkAbout2012-166 S Health - Dr Diane Shugars Dental Services $11,200 (1
ORANGE COUNTY—CONTRACT CONTROL SHEET t lite.e..0.1.441.1—
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. Diane Shugars PartyNendor Contact Person: Dr.Diane Shugars Contact Phone: PartyNendor
Address: 3310 Environ Way City Chapel Hill State:NC Zip:27517 Department: Health Amount: $ Purpose: Provide Dental
Services to Patients Budget Code(s): 10410120 630000 Vendor#56709 (N/A if new vendor) Vendor is a BOCC consultant? Yes El
No11 Contract Type: (Check one)New 0 Renewal Eg Amendment 0 Effective Date July 1,2012 Approved by Board Yes0 No
0 Agenda Date: Title of Contract:
If this is a Grant Agreement, pre-application has been approved by the Board of Commissioners Yes0 No0. If submitted for bid were
bids/RFPs received Yes0 No0 Bid/RFP number This contract has been reviewed and approved by the Department Director as to
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technical content:
Department Director's signature: Date: (B 00)0,
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 Management
Include the following coverages: 0 CGL; 0 Auto; 0 WC; g•firofessional; 0 Property; 0 OR No Insurance Required E. 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: 3 62-u
a/MLA, /4-' Date:
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er. ree 4,61.2,/,,,A_
Financial Services
This Contract is conditioned upon appropriation by the Board of Commissioners Yes0Nogf. A budget amendment is necessary
before approval Yes0 NoNl. 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 Co trol Act:
Financial Services Director's Signature: &A-LA. 1 . 4"4"-■ Date: If 4 ( 2-
---- cz. .. L.it°1
County Attorney
Approval by Board 1:1 (Contra s over $90,000.00 for goods or services, $250,000.00 for construction, or any BOCC consultant
contract). Approval by Manager ,i1 (All ,a er contracts). This contract has been reviewed and approved by the Attorney as to legal
form and sufficiency:
Attorney's Signature f Date: 7 ,11 1 2_
County Manager
This contract has been reviewed and is approved by the County Manager YesKcioE.
This contract has been reviewed and is to be s bmitted for :OCC consideration Yes0NoEir." •
/
Manager's Signature: fl .1 410 Date:7- ib- /2--
MI
r
Clerk to the Board
Approved by BOCC on the day of _,20 . Submitted for Chair signature on the day of
, _,0
_ .
Clerk's Signature: _ Date:
Revised April 2010