Special Services Form

Request for Special Services

SS #:

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:

BKCMP

BKASI

BKFDN

BKSTU

BKFFR

BKSPA

VENDOR:

DATE:

NAME:

SSN#:
(MANDATORY)

TITLE:

TOTAL AMOUNT
DUE:
NOT TO EXCEED $2,500.00

ADDRESS:
(MANDATORY)

CITY:

PHONE:

STATE:

ZIP:

DESCRIPTION OF
SERVICES:

TO BE PICKED UP FROM CASHIER'S WINDOW
BY DEPT. REP.

Print name & extension

DATE OF
SERVICES:

TO BE MAILED TOABOVE 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.

__________________________________________________
Claimant Signature

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

Department Authorization:

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

Requested by

__________________________________________________
Requester Signature

Approver Print name

__________________________________________________
Department Approved Signature

Account:	Fund:	Department:	Program:	Project:	Class: