HomeMy WebLinkAboutR 2014-463 Finance - Cynthia Gamble to provide dental services patient care at the OCHD clinics 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: Cynthia Gamble Party/Vendor Contact Person: Cynthia Gamble Contact Phone: 919-380-1042 Party/Vendor
Address: 114 Oakmist Dr City Cam State:NC Zip:27513 Department:Public Health Amount: $11,200 Purpose:Provider will render
professional dental services patient care at the OCHD clinics Budget Code(s): 10410120-630000 Vendor#59544 (N/A if new vendor)
Vendor is a BOCC consultant? Yes❑No® Contract Type:(Check one)New❑ Renewal® Amendment ❑ Effective Date Ju�L
2014 Approved by Board Yes❑No❑ Agenda Date:July 1 2014-June 30,2015 Title of Contract: Cynthia Gamble
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: 1
Department Director's Signature: e Date:
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:
1 r nature: Date:
Ris ement
Include the following coverages: ❑ C Professional; ❑ Property; OR No Insurance Required ❑. Hold
Contract pending re ertificate of Insurance ❑. With incorporatio nce provisions as sho FA—U s PbnTc0isTppM
b anager: �C �J �j LC Risk Manager's Signature: � %�� — Date G 2 5 2014
8l zs
Financial Services By
This Contract is conditioned on appropriation by the Board of Commissioners Yes❑No A budget amen t e
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 Bud mt And F-is-cal C'ontrol t:
Financial Services Director's Signature: �Jl G�G�IN Date:
County Attorney
Approval by Board ❑ (Contracts $90,000. 0 or more for goods or services, $250,000.00 or more for construction, or any BOCC
consultant contract). Approval by an erq(Most other contracts$1,000 and above). Department Director approval only❑ (Under
$1,000). This contract has been rev e and approved by the Attorney as to legal form and sufficiency:
Attorney's Signature Date:
County Manauer
This contract has been reviewed and is approved by the County Manager Yes61o❑.
This contract has been reviewed and' r si nature b the Chair No❑. !
Manager's Signature: Date:
Clerk to the Board
Approved by BOCC on the_day of ,20 . Sub fa Chair signature on th _day of ,20
Clerk's Signature: Date: �
Revised March 2012