HomeMy WebLinkAbout2023-406-E-Health Dept- Shahab Siahpoosh- Dental Hygienist Services AgreementRevised 04/23
NORTH CAROLINA
CONTRACT AMENDMENT
ORANGE COUNTY
THIS CONTRACT AMENDMENT (“Amendment”) is made and entered into this 8th day of August, 2023 by and
between ORANGE COUNTY (hereinafter referred to as “County”) and Shahab Siahpoosh (hereinafter referred to as
“Provider”).
WITNESSETH:
THAT WHEREAS, the County and Provider entered into a contract dated June 8, 2023, (hereinafter the “Original
Agreement”), for the provision of services for dental services; and
WHEREAS, the County and Provider desire to amend the Original Agreement while keeping in effect all terms and
conditions of the Original Agreement not inconsistent with the terms and conditions set forth below.
NOW THEREFORE, for and in consideration of the mutual covenants and agreements made herein, the parties agree to
amend the Original Agreement as follows:
1. Article 5, Section a. is amended to reflect a maximum payable not-to-exceed amount of $10,000.00.
2. Except for the changes made herein, the Original Agreement shall remain in full force and effect to the extent
it is not inconsistent with this Amendment. In the event there is a conflict between the terms of the Original
Agreement and the terms of this Amendment, this Amendment shall control.
IN TESTIMONY WHEREOF, this Amendment has been executed by the parties hereto, as of the date first above
written.
ORANGE COUNTY PROVIDER
______________________________ __________________________________
Bonnie Hammersley Shahab Siahpoosh
County Manager
DocuSign Envelope ID: 95FBCF6F-BA3A-420D-A1F4-BCA41C85CAC9
Revised 04/23
ORANGE COUNTY—INTERNAL USE ONLY
______________________________________________________________________________
Finance Information
Vendor Name: Shahab Siahpoosh Vendor Contact Person: Shahab Siahpoosh Phone: 252-432-2935 Address: 1520 Pebble Creek
Xing City Durham State: NC Zip: 27713 Department: Health Amount: $4,000 Purpose: Dental Hygienist Services Agreement
Budget Code(s): 10410120-630000 Vendor # 68081
Vendor Status with NCSOS: Vendor is a BOCC consultant: Yes No
Contract Details
Contract Type: New Amendment (Original Contract: 2023-250-E) (Most Recent Amendment )
Effective Date 8-15-23 End Date 6-30-24 Notice Date (Notice Purpose )
Award
Approved by Board (Agenda Date: ); Made or Administered by
Signature Authority
- BOCC Express Delegation (Agenda Date: )
- Policy 9.4: Under $5,000; Service Under $90,000; Construction Under $250,000
- Budget Policy Section XV (Capital Improvement Project: )
Bidding
Informal Bidding ($30k-$90k); Formal RFP ($90k+); Other (<$30k); Exception(# )
Department Affirmation
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.
Services related to this agreement have already begun or been completed. Description of the nat ure of the emergency condition that
was addressed:
Department Director’s Signature ________________________________________ Date: ________
Information Technologies
This agreement has been reviewed and is approved as to information technology content and specifications:
Office of the Chief Information Officer___________________________________ Date: ________
Inapplicable because no hardware/software purchases or related services
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
All Docusign contracts must be copied to the Clerk upon completion: occlerkdocs@orangecountync.gov
The following signature block is for hard copies only and is not required for Docusign contracts:
Received for record retention:
Office of the Clerk to the Board __________________________________________Date:_________
DocuSign Envelope ID: 95FBCF6F-BA3A-420D-A1F4-BCA41C85CAC9
8/9/2023
8/9/2023
8/9/2023
8/11/2023
Revised 04/23
DocuSign Envelope ID: 95FBCF6F-BA3A-420D-A1F4-BCA41C85CAC9