HomeMy WebLinkAboutR 2019-710 Health - Triangle Urology vasectomy services DocuSign Envelope ID: B78A3FOE-AA4A-4AA8-BO30-351CO676A960
ORANGE COUNTY-DEPARTMENT USE ONLY
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: $10,200 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 10-4-19 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 10/4/2019
Department Director's Signature[aCisFzoosEsa45F. 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 Wcusigned by: rds,specifications,and requirements:
��tsa' ��'t'�6 10/9/2019
Office of the Risk Management Office 7MCFs176s004ss. Date:
Financial Services
This instrument has been pre-audited in the manner required by the Local Government Budget and Fiscal Control
Act: DocuSigned by:
A 10/9/2019
Office of the Chief Financial Officer 7Da�s4a1ACC1409. Date:
Legal Services
This agreement is approved as to Ffl
DocuSigned by: {�
"J, � l�S(h 10/9/2019
Office of the County Attorney_ 079MDQSCOF4FB. 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
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