HomeMy WebLinkAboutR 2015-684 Health - Elizabeth Krzysztoforska dental services.pdf,Rev. 7/15 8
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 # 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 technical form and content:
Department Director’s Signature ________________________________________ Date: ________
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 sufficiency of insurance standards, specifications, and requirements:
Office of the Risk Management Officer___________________________________ Date: _________
Financial Services
This instrument has been pre-audited in the manner required by the Local Government Budget and Fiscal Control Act:
Office of the Chief Financial Officer ____________________________________ Date: _________
Legal Services
This agreement is approved as to legal form and sufficiency:
Office of the County Attorney __________________________________________Date: ________
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:_________
DocuSign Envelope ID: 045AF678-3763-4394-A072-D12B1E113359