HomeMy WebLinkAboutR 2016-418-E Health - Elizabeth Krzysztoforska for dental services DocuSign Envelope ID:93039227-OC40-4DA1-8CBE-17FBAOEE6AEE
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: 447 FEARRINGTON POST City
PITTSBORO State: NC Zip: 27312 Department: HEALTH Amount: $35,000 Purpose: DENTAL SERVICES Budget
Code(s): 10410120-630000 Vendor # 30702 (N/A if new vendor) Vendor is a BOCC consultant? Yes ❑ No[]
Contract Type: (Check one)New ❑ Renewal ® Amendment ❑ Effective Date 7/1/2016 Approved by Board Yes
❑No❑ Agenda Date:
This agreement is approved as to to i7icaft' "eaa�id content:
��"� 8/1/2016
Department Director's Signature C9ED9DOFC6B545E.. Date:
Information Technolo0es
(Applicable only to hardware/software purchases or related services)This agreement has been reviewed and is approved
as to information technology content and specifications:
Office of the Chief Information Officer Date:
Risk Management
This agreement is approved for sufficienc o 1ft �"Mtandards, specifications,and requirements:
�!,DCF9176800498 USA. V'l�tkN 8/1/2016
Office of the Risk Management Officer ... Date:
Financial Services
This instrument has been pre-audited i t c nan$er inquired by the Local Government Budget and Fiscal Control Act:
Office of the Chief Financial Officer �4 a1ACC1409... Date: 8/2/2016
Legal Services
This agreement is approved as t eg�P`14§t�I'fda�hl sufficiency:
� 1� 8/3/2016
Office of the County Attorney �S�RR��a�oaoo Date:
Clerk to the Board
Received for record retention:
All Docusign contracts must be copied to Donna Lloyd upon completion @ Dolloydkorangecount.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:
Rev. 6/16 9