HomeMy WebLinkAboutR 2019-418 Health - Advanced Dental Associates service contract DocuSign Envelope ID: DC123A99-06A0-46CF-848C-67887A7D9680
ORANGE COUNTY—DEPARTMENT USE ONLY
Party/Vendor Name: Advanced Dental Associates, Inc. Party/Vendor Contact Person: Mindy Gill Contact Phone:
919-545-0985 Party/Vendor Address: 11312 US 15-501 North, Suite 107-139 City Chapel Hill State:NC Zip: 27517
Department: Health Amount: $2,000 Purpose: Referral of licensed dental personnel Budget Code(s): 10410120-
630000 Vendor#64922 (N/A if new vendor) Vendor is a BOCC consultant? Yes ❑No® Contract Type: (Check
one)New ❑ Renewal ® Amendment ❑ Effective Date 7-1-19 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:
DocuSigned by:
S&Wof 7/10/2019
Department Director's Signatur 3C18F2D09E3445F. 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 sufficient DocuSigned by: rds,specifications,and requirements:
aUS66 (, 6 7/10/2019
Office of the Risk Management Office El
. Date:
Financial Services
This instrument has been pre-audited i Docusigned by: the Local Government Budget and Fiscal Control Act:
'� -" 7/10/2019
Office of the Chief Financial Officer 7DaE5aa1ACC1499. Date:
Legal Services
This agreement is approved as t D"USigned by:
'"'1` havit, T 6SL6 7/10/2019
Office of the County Attorney 079A4D525C0F4Fa. Date:
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:
Revised 12/18 4