Independent Contractor (Ic) Checklist Page 2
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10INDEPENDENT C ONTRACTOR B UDGET A PPROVAL F ORM
Independent C ontractor I nformation
Tracking # :
Last N ame, F irst N ame, M I:
Address:
City, S tate, Z IP:
Telephone:
Fax:
Email:
Is t his I ndependent C ontractor a U .S. C itizen o r a P ermanent R esident A lien? Y es N o
If N o, c omplete t he f orm l ocated o n t he O ffice o f G lobal E ducation’s w ebsite p rior t o c ompleting t he I C p acket i n o rder t o v erify
eligibility t o r eceive p ayment f or s ervices. h ttp://
Is t his I ndependent C ontractor a n e mployee o f t he C SU s ystem o f h ave t hey b een w ithin t he l ast 2 4 m onths? Y es N o
If y es, w hich C SU c ampus:
Faculty
Non-‐Faculty
Detailed D escription o f S ervices t o b e p rovided:
Multiple P ayments: i f m ultiple p ayments a re r equired, p lease l ist t he p ayment d ates a nd a mounts h ere. P ayments m ust e qual t he
amount ( s) l isted b elow u nder f unding s ource.
Work t o C ommence b y: W ork t o b e c ompleted b y:
Acknowledgement
I, t he u ndersigned, h ereby d eclare t hat t he i nformation p rovided i n t his d ocument i s t rue a nd c orrect a nd t hat I h ave s ufficient
knowledge o f, a uthority, a nd r esponsibility f or t he w ork t o b e p erformed u nder t his c ontract t o e ffectively m ake t his
determination.
Funding S ource ( do n ot c hange a ccount n umber)
Account
Fund
Dept
Pgm
Class
Project
Amount
Approving A uthority ( Must h ave f iscal a uthority)
613001
Print N ame:
Signature:
613001
Print N ame:
Signature:
613001
Print N ame:
Signature:
613001
Print N ame:
Signature:
Grand T otal:
Requested b y p rinted n ame:
Date:
Procurement S ignature:
Date:
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