HomeMy WebLinkAboutR 2019-416 Health - Ibrahim Ackall, DDS dental services DocuSign Envelope ID:60428CE2-9935-40E5-A253-2BFC8FE8BF27
ORANGE COUNTY—DEPARTMENT USE ONLY
Department
Party/Vendor Name: Ibraheem G. Ackall, DDS Party/Vendor Contact Person: 1. George Ackall, DDS Contact Phone:
719-691-1162 Party/Vendor Address: 405 Perry Creek Dr. City Chapel Hill State:NC Zip: 27514 Department: Health
Amount: $4,000 Purpose: Dental Services Budget Code(s): 10410120-630000 Vendor# 65708 (N/A if new vendor)
Vendor is a BOCC consultant? Yes ❑ No® Contract Type: (Check one) New ® Renewal ❑ Amendment ❑
Effective Date 7/1/2019 Approved by Board Yes❑No❑ Agenda Date:
This agreement is approved as to technical form and content and I as Department Director affirmatively state work on this
project has not been initiated prior to execution of the agreement:
OceuSigned by:
�� S�_Wof 7/1/2019
Department Director's Signature 3C16F2D09E3445F. Date:
Agreements for emergency services or repair are not subject to the above affirmation. If services related to this
agreement have already begun or been completed please briefly describe the nature of the emergency condition that was
addressed:
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 oo'� cusigppned by:' ' •ds, specifications,and requirements:
aUsa LQ 6 7/8/2019
Office of the Risk Management Officer Date:
7F6CF917880049,.
Financial Services
This instrument has been pre-audited i Docusigned by: the Local Government Budget and Fiscal Control Act:
Office of the Chief Financial Officer CC 704E59S1ACC1409 Date: 7/8/2019
.
Legal Services
This agreement is approved as t D"uSigned by:
'WAk �t, U(h 7/8/2019
Office of the County Attorney o79A4D525COF4Fa. Datc:
Clerk to the Board
Received for record retention:
All Docusign contracts must be copied to Sherri Ingersoll upon completion: singersoll@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:
Rev. 6/19 8