HomeMy WebLinkAboutR 2018-494 Health - Triangle Urology vasectomy servicesDocuSign Envelope ID: 5D924F8F- OA84- 4ECE- 95C8- E82E8DA18036
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: Health
Amount: $3,400 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 -18 Approved by Board Yes❑ No❑ Agenda
Date:
This agreement is approved as to to e2*fWntand content:
Sft,Wa
Department Director's Signature v a�ta Date: 8/22/2018
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
Risk Management
Date:
This agreement is approved for sufficienc iosm# aaaystandards, specifications, and requirements:
�
r gtS A. rbl b Office of the Risk Management Officer er9176888498... Date: 8/23/2018
Financial Services
This instrument has been pre - audited i 1wquired by the Local Government Budget and Fiscal Control Act:
0././. 8/23/2018
Office of the Chief Financial Officerec,4os Date:
Legal Services
This agreement is approved as t c9of'�SY'l qEd su- fiiciency:
Ql�Ui1- kavi , i wb 8/23/2018
Office of the County Attorne 079GdfK,FCOFdFR Date:
Clerk to the Board
Received for record retention:
All Docusign contracts must be copied to Sherri Ingersoll upon completion: sin erg sollgoran eg countync.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 10/17 (Mgr appry 5k 6/18) 4