Request for Special Services


  SS #:
CSUB logo  For one time services to individual, not EMPLOYEES or STUDENT ASSISTANTS, of the university. Please allow 10 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.

  __________________________________________________
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.
 

  __________________________________________________
Requester Signature   

 

  __________________________________________________
Department Approved Signature