HomeMy WebLinkAboutR 2016-320-E Health - Triangle Urology Associates, P.A. - vasectomy services to OCHD referred males DocuSign Envelope ID: 58340D10-53F7-460D-9D47-DA2ED9BEB980
ORANGE COUNTY-DEPARTMENT USE ONLY
Department
Party/Vendor Name: Triangle Urology Associates, P.A. Party/Vendor Contact Person: Pat Grinstead Contact Phone:
919-313-3662 Party/Vendor Address: 205 Frasier Street City Durham State: NC Zip: 27704 Department: Health
Amount: $8.000 Purpose: Provide vasectomy services to OCHD referred mailes. Budget Code(s): 10414020-630000
Vendor# 63847 (N/A if new vendor) Vendor is a BOCC consultant? Yes ❑ No® Contract Type: (Check one)
New ® Renewal ❑ Amendment ❑ Effective Date 7/1/16 Approved by Board Yes❑ No❑ Agenda Date:
This agreement is approved as to to ftlufi"9t1 l%.d content:
6/15/2016
Department Director's Signature Date:
Information Technolosies
(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 sufficienc d UMstandards, specifications,and requirements:
ausa, r,6rin,c,�16 6/15/2016
Office of the Risk Management Officer FBSF�z&9eeaN Date:
Financial Services
This instrument has been pre-audited i Dlga*i or-quired by the Local Government Budget and Fiscal Control Act:
Office of the Chief Financial Officer Lita Date: 6/22/2016
Legal Services
This agreement is approved as t RT�RffdaWd sufficiency:
Office of the County Attorney Date: 6/23/2016
Clerk to the Board
Received for record retention:
All Docusign contracts must be copied to Donna Lloyd upon completion @ Dolloy(d c�orangecount.nic.gov
The following signature block is for hard copies only and is not required for Docusign contracts:
Office of the Clerk to the Board Date:
Revised 6/16 5