HomeMy WebLinkAboutR 2014-301 Health - M. Monica Meng-Haggerty for services to OCHD's dental clinic 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
Party/Vendor Name: M.Monica Meng-Haggerty Party/Vendor Contact Person: M.Monica Meng;Haggerty_ Contact Phone:
Party/Vendor Address:215 Bluefield Rd. City Chapel Hill State:NC Zip: 27517 Department: Public Health Amount: $11,200.00
Purpose: Provider shall provide services to OCHD's Dental clinic Budget Code(s): 10410120-630000 Vendor#N/A (N/A if new
vendor) Vendor is a BOCC consultant? Yes❑No® Contract Type: (Check one)New® Renewal❑ Amendment ❑ Effective
Date July 1,2014 Approved by Board Yes❑No❑ Agenda Date: Title of Contract:M.Monica Meng-Haggerty_
If this is a Grant Agreement,pre-application has been approved by the Board of Commissioners Yes❑No❑. If submitted for hid 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: Date: _ jy
T Director
(Applicable only to hardware/software purchases or related services)This contract has been reviewed and approv n ormation
Technology Director as to technical content and information technology specifications:
nature: Date:
Risk Manallement
Include the following coverages: ❑ CGL; ❑ Auto; ❑ WC; ❑ Professional; ❑ Property; OR No Insurance Required ❑. Hold
Contract pending receipt of Certificate of Insurance ❑. With incorporation of Insurance provisions as shown,this contract is approved
by the Risk Manager: 1
Risk Manager's Signature: Date: G
Financial Services
This Contract is conditioned pon appropriation by the Board of Commissioners Yes❑No A budget amendment is necessary
before approval Yes❑No[. 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 ct: /
Financial Services Director's Signature: Ji/"`� Date: t'
LrLzo
County Attorney
Approval by Board ❑ (Contracts $90,000.00 or more for goods or services, $250,000.00 or more for construction, or any BOCC
consultant contract). Appro a by Manager Most other contracts$1,000 and above). Department Director approval only❑ (Under
$1,000). This contract has ee viewed an approved by the Attorney as to legal form and sufficiency:
Attorney's Signature Date: G
County Manauer
This contract has been reviewed and is a ro d by the County Manager Yeso❑.
This contract has been reviewed is s gn ture e Chair Yes❑No❑.
d
Manager's Signature: A&VIE ot z Date:
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 March 2012