HomeMy WebLinkAboutR 2017-399-E Health - Triangle Urology Associates, P.A. to provide vasectomy services to OCHD referred males DocuSign Envelope ID: 111672FC-E5A1-4E39-A023-8AC8C18839C7
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: 27707 Department: Helath
Amount: $8,000 Purpose: Provide vasectomy services to OCHD referred males. Budget Code(s): 10414020-630000-
71400 Vendor#63847 (N/A if new vendor) Vendor is a BOCC consultant? Yes ❑ No® Contract Type: (Check
one) New ❑ Renewal ® Amendment ❑ Effective Date 7-1-17 Approved by Board Yes No Agenda
Date:
This agreement is approved as to to tm�d'co11n��tent:
7:72.
rlt,c-Att 8/17/2017
Department Director's Signature Date:
5E48F...
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 sufficienc .7[ins�i m 'standards, specifications, and requirements:
aMMS& CbVrn {b 8/17/2017
Office of the Risk Management Officer 7 Qe,4„= Date:
Financial Services
This instrument has been pre-audited i chittliffd P quired by the Local Government Budget and Fiscal Control Act:
�
Office of the Chief Financial Officer �� Date: 8/21/2017
�B4E5181ACC1100...
Legal Services
This agreement is approved as t n l=4i�t Nid sufficiency:
al',U Aunt, 1 I Scb 8/21/2017
Office of the County Attorney Date:
o7-07
Clerk to the Board
Received for record retention:
All Docusign contracts must be copied to Donna Lloyd upon completion @ Dolloyd@orangecountync.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 2/17 5