Request for Special Services


  SS #:
CSUB logo  For one time services to individual, not EMPLOYEES or STUDENT ASSISTANTS, of the university. Please allow 7 working days for processing.   It is customary to pay claimant at conclusion of service.
see instructions    BUSINESS UNIT:   
 
 
 
 
 
 
 
TO BE FROM CASHIER'S WINDOW
BY DEPT. REP. 



 
TO BE ABOVE ADDRESS AFTER COMPLETION OF SERVICES.
DISPOSITION OF CHECK: 
I understand that I am not an employee or agent of the the above mentioned Business Unit, that I am solely liable and responsible for all Federal and State taxes, that I am not covered by Worker’s Compensation or Unemployment Insurance or eligible for any fringe benefits, and that I agree to hold this Business Unit harmless from any liability resulting from work performed relative to this agreement. I further agree to indemnify and/or defend the Business Unit in any legal proceedings that arise out of the performance of this contract by any party.

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Claimant Signature    
NOTE: Make sure values on form are correct as VALUES ARE CLEARED BEFORE PRINTING AND FORM IS REFRESHED!
   
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Department Authorization:

 I hereby certify that the services described above have been completed and that payment is now requested.
 

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Requester Signature   

 

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Department Approved Signature