HomeMy WebLinkAboutR 2014-458 Finance - Diane Shugars to provide professional dental services at the OCHD clinics RANGE 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: Diane Shugars Party/Vendor Contact Person: Diane Shugars Contact Phone: Party/Vendor Address: 908
Higligrove Dr. City Chapel Hill State:NC Zip:27516 Department:Public Health Amount: $11,200.00 Purpose:Provider will render
professional dental services at OCHD clinic Budget Code(s): 10410120-630000 Vendor#56709 (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:July 1 2014-June 30,2015 Title of Contract:Diane Shugars
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: // Date: 'l f
I irector
(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: ❑ CGL; ❑ Auto; ❑ WC; ❑ Professional; ❑ Property; OR No InsuranT_ Hold
Contract pending receipt of Certificate of Insurance ❑. With incorporation of Insurance provisions as shown,jt~1i (orcj5s(�pi
by the Risk Manager:
l,lI AUG G 12014
Risk Manager's Signature: Date:
8 L zl y
Financial Services
This Contract is conditioned on 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 t:
Financial Services Director's Si g nature: �
W - %111, 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 M ager (Most other contracts$1,000 and above). Department Director approval only❑ (Under
$1,000). This contract has been revi w d and approved by the Attorney as to legal form and sufficiency:
Attorney's Signature Date: z La �q-
County Manager
This contract has been reviewed and is approved by the County Manager Yes o❑.
This contract has been reviewed and is for signature by the Chair Yes❑No❑.
Manager's Signature: Date:
Clerk to the B and
Approved by BOCC on the—day of ,20 . S e r Chair signature on the day of 120
Clerk's Signature: Date:
Revised March 2012