Agreement And Payment Request Form

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HUMBOLDT STATE UNIVERSITY
Arcata, California 95521
GUEST LECTURER/ SERVICE PROVIDER
(Independent Contractor)
AGREEMENT AND PAYMENT REQUEST
DATE: _______________________________________
Procurement & Support Services
TO:
Student & Business Services Building Suite 413
________________________________________ Department Requesting Services
FROM:
Service Provider: ___________________________________________ Employee ID No. ________________________
Home Address: ____________________________________________________________________________________
Date(s) services provided: ____________________________________________________________________________
COMPLETE DESCRIPTION OF SERVICES PROVIDED: ___________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_______________________________________________________Cost of Service $ ____________________________
Signature of Service Provider
Attachments: Std. 204 (Vendor Data Record)
FOR UNIVERSITY USE ONLY
FUNCTION ____________________________________
Check to be given to service provider
upon completion of services
COLLEGE/ AREA _______________________________
Check to be mailed to service provider
DEPARTMENT _________________________________
by the State Controller
ACCOUNT CODE _______________________________
APPROVED:
I certify that the services described above have been com-
pleted and that funds are available to make
payment.
______________________________________________
____________________________________________
Department Head
Procurement & Support Services
SEE REVERSE FOR INSTRUCTIONS
Distribution:
Original and 2 copies to Procurement & Support Services
1 to Requesting Department
1 to Guest Lecturer/ Service Provider
# 64

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