PO RE DENTAL SEALANT WITH ADHS.PDF

C -Y6'13 -- 06 11 -/3 -0 3
ARIZONA STATE CONTRACT Page 1 of 2
CONTRACT RELEASE
ProcureAZ Purchase Order No.: ADHS13-037845:3
Organzational Reference No.: E0149272
issued: 01/28/2014
Vendor Number: 000010983 Arizona Department of Health Services
Maricopa County Public Health Bureau of Women and Children's Health
4041 N. Central Avenue, #1400 150 N. 18th Avenue, Suite 320
Phoenix, AZ 85012 Phoenix, AZ 85007
US
Email: procure@azdhs.gov
Contract No.: ADHS13-037845 12) 364-1400
Tale: Dental Sealant Services
.1 MAIL INVOICE IN DUPLICATE TO:
13; Arizona Department of Health Services
.1 Bureau of Women and Children's Health
150 N. 18th Avenue, Suite 320
Phoenix, AZ 85007
US
Email: procure@azdhs,gov
(602) 364-1400
Release Instructions
TERMS AND CONDITIONS set forth in our Bid, Quotation, or Purchase Order
are incorporated herein by reference and become a part of this order.
Account Code: 14-99401-45301-6811- Payment Terms: Net 30
Shipping Terms:
Solicitation (Bid) No.: Delivery Calendar Day(s)A.R.O.: 0
Item Description Requisition Quantity Unit Unit Price Total
Class-Item 948-28
1200.00 EA • $ 70.00 $ 84,000,00
PC EFFECTIVE 1/1/14 - 12/31/14 *** CONTRACT EFFECTIVE 1/1/13 -
12/31/17 *** THIS LINE TO PAY FROM 73511/ 45301 ********"*—"*".
'Dental sealant services - Der child
Class-item 948-28
2 2029.00 EA $ 70.00 $ 142,030.00
THIS LINE TO PAY FROM 99401/ 45301 ****"* Dental sealant services -
_pier child
Class-Item 948-28
3 214.00 EA $ 70.00 $ 14,980.00
THIS LINE TO PAY FROM 94773/ 45301 **" Dental sealant services - per
child

Page 2 of 2
ARIZONA STATE CONTRACT
CONTRACT RELEASE
Class-Item 948-28
4 1.00 EA $ 13,323.00 $ 13,323.00
THIS LINE TO PAY FROM 99401/ 45301 **** Cost Effectiveness
Evaluation
Class-Item 948-28
5 1.00 EA $ 13,323.00 $ 13,323.00
THIS LINE TO PAY FROM 99401/ 45301 ""*"*"Customer Satisfaction
Survey and Assessment Results
Class-Item 948-28
6 1.00 EA $ 13,324.00 $ 13,324.00
THIS LINE TO PAY FROM 99401/ 45301 '"'"'" Program Implementation
Analysis and Assessment
TOTAL: $ 280,980.00
Approved By: Dee Vlahos
Phone No.: (602) 364-1425

C-86-13-064-3-03 ATTACHED TO AND A PART OF
Purchase Order ADHS13-037845:3
Dental Sealant Services
IN WITNESS WHEREOF, the parties agree to enter into this Contract:
FOR AND ON BEHALF OF
MAR1COPA COUNTY
By
Chairman, Board of Supervisors
Date
ATTEST:
Clerk of the Board
Date
APPROVED AS TO FORM:
Attorney for Maricopa County
Date