Version 07 2019
TO: Contract Office, Box 70729 Contract Number_________________________
(Assigned by Contract Office)
Amount $_________________
Expense Revenue
No Cost
Chart & Index ____ - _____________
Contract Term: _______________ to ________________
# of Renewals _________
ETSU Department: _________________________________ Responsible Person: _______________________________
Contractor Name: _______________________________________________ Contractor E# _______________________
Contractor Address: _________________________________________________________________________________
Purpose of Agreement: ______________________________________________________________________________
If this agreement is $10,000 or more provide the bid documentation or sole source justification.
Type of Agreement:
Dual Admissions
Service w/ Business
Business Associate
Dual Services
License Software
Service w/ Person
Clinical Affiliation
Facility Usage
Crafter License
International Studies
Amendment to Contract # ____________________
I hereby declare that the information provided in this document is true and correct and that I have sufficient knowledge of
authority and responsibility for the work to be performed under this agreement to effectively make this certification.
_______________________________________ _________ ______________________________________ _________
Signature of individual completing this form Date Approval Date
Department: ____________________________________________________________ Box #: ___________
Name: _____________________________________________________ Phone: ______________________
If this agreement is for SERVICES with a PERSON complete the following:
Is this payment being made to or on behalf of a U.S. citizen or legal permanent resident? Yes No
If no, contact the Office of Nonresident Alien Tax Compliance at 423-439-6887 or
Is the PERSON an employee of ETSU, another State/TBR school, or a State of Tennessee agency? Yes No
A.) Do other ETSU employees perform essentially the same duties that are to be performed by this PERSON? Yes No
B.) Has this PERSON previously been paid as an ETSU employee to perform essentially these same tasks? Yes No
If the answer to question A and/or B is YES, the worker must be classified as an employee and hired in accordance with personnel policies.
If the answers to questions A and B are both NO, the Employee vs. Independent Contractor Classification Criteria form must be completed: