HomeMy WebLinkAbout2012-167 S Health - Dr Cynthia Gamble for Dental Services - $11,200 ZCD1Z—!Ler/
ORANGE COUNTY—CONTRACT CONTROL SHEET
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. Cynthia Gamble PartyNendor Contact Person: Dr.Cynthia Gamble Contact Phone: Party/Vendor
Address: 114 Oakmist Drive City Cary State:NC Zip: 27513 Department:Health Amount: $ Purpose: Provide Dental Services to
Patients Budget Code(s): 10410020 630000 Vendor# 59544 (N/A if new vendor) Vendor is a BOCC consultant? Yes 0 Nor.
Contract Type:(Check one)New 0 Renewal g Amendment n Effective Date July 1,2012 Approved by Board Yes0 No
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
technical content: _
Department Director's Signature: Date: 6 la I ia
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 Matjagement
Include the following coverages: El CGL; 0 Auto; 0 WC; 1E- rofessional; 0 Property; 0 OR No Insurance Required 0. Hold
Contract pending receipt of Certificate of Insurance 0. With incorporation of Insurance provisions as shown, this contract is approved
by the Risk Manager:
Risk Manager's Signature: ym t_dk, cit td.. Date: 62 •1-4?. lz-/
ro 0672/42 342/1r)%4 alb
Financial Services
This Contract is condition upon appropriation by the Board of Commissioners Yes0NoN. A budget amendment is necessary
il
before approval Yes0 N c . If budget amendment is necessary,please attach to this form. This instrument has been pre-audited in the
manner required by the Loca Government Budget and Fiscal Control Act:
Financial Services Director's Signature: AU-LA.- A dalitA-■ Date: 7121 17.-
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County Attorney
Approval by Board 0 (Contracts over $90,000.00 for goods or services, $250,000.00 for construction, or any BOCC consultant
att
contract). Approval by Ma y r (All other contracts). This contract has been reviewed and approved by the Attorney as to legal
/s
form and sufficiency: 1
N. .. „Pr ‘ 7 1
Attorney's Signature Date: • IZ-
1
County Mana2er
This contract has been reviewed and is approved by the County Manager Ye.52/-No0.
This contract has been reviewed and is to be submitted for OCC consideration Yes[]NoEr
Manager's Signature: Date: 7— (0 --/t/
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