Okaloosa County BOCC — July 21, 2015 — DR TANNER RENEWAL

AN CONTRACT & LEASE INTERNAL COORDINATION SHEET Contract/Lease Number: (’O ?-/7;1’_/)5 Tracking Number:_/ 3 § 2’2 5 i B T Grant Funded: YES NO Contractor/Lessee Name: Dp d)wjéyylww /@4—:\9«-\— Purpose MMLL(M / / Date/Term: ?/36 // % 1. ] GREATER THAN $50,000 Amount: 2& /(&', m 2. I:l GREATER THAN $25,000 Department: Fg 3. [] $25,000 OR LESS Dept. Monitor Name: \//g&,u_/ /&/‘1’/‘\_ Document has been reviewed and includes any attachments or exhibits. Purchasing Review .“ Y v . ‘ ' W 2 ) oater_ /745 Pu,/chasing Dfrector/o'r Designee Joanne Kublik or Sunnie Estes g Risk Management Review Approved as written: M %&-\ Date: (()" ;c?"15 ) Risk Ménage‘r or designee Laura Porter or Krystal King County Attorney Review Approved as written: | L’X’\A i' ’-Q}\.:\_)(}”\' Date: b S “’f - “:) Co nty@tor\wey Gregory T. Stewart or Lynn Hoshihara — Following Okaloosa County approval: Contracts & Grants Document has been received: Date: Contracts & Grants Manager CONTRACT/LEASE RENEWAL FORM May 18, 2015 | CONTRACT # C09-1 Dr. Christopher D. Tanner DR. CHRISTOPHER E21T:3NER M.D P.0. Box 5500 MEDICAL EXAMINER ' Destin, FL 32540 EXPIRES: 09/30/2016 RE: Contract #C09-1721-PS Dear Dr. Tanner, The Okaloosa County Board of County Commissioners agrees to renew the subject contract/lease, # C09-1721-PS for an additional term. The contract renewal period will be 10/01/2015 to 09/30/2016 . The annual budgeted amount for this contract is $.16,000.00 . All other terms and conditions of the original agreement shall remain in full force and effect through the duration of this renewal. If you are in agreement, please sign below and return this form along with a current Certificate of Insurance listing Okaloosa County as co-insured (if applicable). COUNTY REPRESENTATIVES AUTHORIZED COMPANY REPRESENTATIVE Dept. Dire@% Contractor: Dr. Christopher D. Tanner, MD Signature: e A.(‘ ino 1ant, Fublic aely irector Date: =5 /20//5" g ; AN L/‘ / Approved By: 2/ L1t pproved By: (—M @ IT (as prescnbed@ow on Date: 7/ J’S Approved By: Title: Medical Director (as prescribed below on item 1) Date: Date: b I/ el //15 County Department Instructions: 1) Obtain signatures from Department Director, authorized Company Representative and then Purchasing Director <$25K and less, County Administrator <$50K and less or Board >$50K, as necessary. If Board approval is required, the Chairman and County Administrator's signatures are required. Make sure the company provides a current Cerlificate of Insurance. (If applicable). 2) Keep a copy of this form for your records. 3) Send original to Purchasing Services Coordinator. If you have any questions please contact the Purchasing Director at 850-689-5960, Fax: 850- 689-5998.