HomeMy WebLinkAboutR 2015-387-E Health - Elizabeth Krzysztoforska to provide dental services DocuSign Envelope ID:045AF678-3763-4394-A072-D12B1E113359
ORANGE COUNTY-DEPARTMENT USE ONLY
Department
Party/Vendor Name: ELIZABETH KRZYSZTOFORSKA Party/Vendor Contact Person: ELIZABETH
KRZYSZTOFORSKA Contact Phone: 336-513-2259 Party/Vendor Address: 128 SUMMERLIN DRIVE City
CHAPEL HILL State: NC Zip: 27516 Department: HEALTH Amount: $35,000 Purpose: DENTAL SERVICES
Budget Code(s): 10410120-630000 Vendor 4 30702 (N/A if new vendor) Vendor is a BOCC consultant? Yes ❑ No
® Contract Type: (Check one)New ❑ Renewal ® Amendment ❑ Effective Date 7/1/2015 Approved by Board
Yes❑No❑ Agenda Date:
This agreement is approved as to to ' hnd content:
Department Director's Signature p Date: 7/24/2015
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Information Technologies
(Applicable only to hardware/software purchases or related services)This agreement has been reviewed and is approved
as to information technology content and specifications:
Office of the Chief Information Officer Date:
Risk Management
This agreement is approved for sufficient sm� "" :''standards,specifications,and requirements:
Q�ASA. r,6vvt,e,tt0 7/24/2015
Office of the Risk Management Office ZEnrpg 7PAnnap Date:
Financial Services
This instrument has been pre-audited i °fl l i >��tquired by the Local Government Budget and Fiscal Control Act:
�AU� �bliL 7/24/2015
Office of the Chief Financial Officer a�F?r�a�az® Date:
Legal Services
This agreement is approved as t RTT(N Ygdai'i'd sufficiency:
Office of the County Attorney --- Date: 7/31/2015
Clerk to the Board
Received for record retention:
All Docusign contracts must be copied to Donna Lloyd upon completion @ DolloyLyorangecou go v
The following signature block is for hard copies only and is not required for Docusign contracts:
Office of the Clerk to the Board Date:
Rev.7/15 8