This page uses JavaScript. Please enable scripts or upgrade your browser.
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 TO
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.
__________________________________________________
Claimant Signature
NOTE: Make sure values on form are correct as VALUES ARE CLEARED BEFORE PRINTING AND FORM IS REFRESHED!
Please download
Adobe Reader
to view PDF files.
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: