Version 07 2019
AGREEMENT ROUTING FORM – COLLEGE OF MEDICINE and FAMILY MEDICINE
TO: Contract Office, Box 70729 Contract Number_________________________
(Assigned by Contract Office)
TO BE COMPLETED BY DEPARTMENT:
Amount $_________________
☐
Expense ☐
Revenue ☐No Cost
Chart & Index ____ - ____________
Contract Term: _________________ to __________________
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:
☐ 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: ______________________
____________________________ ___________ ____________________________ __________
Associate Dean Date Dean Date
Return by mail to COM F&A, Building 178, P.O. Box 70420
FOR CONTRACT OFFICE USE ONLY
Encumber ☐ Yes ☐ No Financial Consideration $_____________
To be signed by: ☐Pres ☐AA ☐Admin ☐Ath ☐B&F ☐HA ☐SA ☐UA
Reviewed for content by University Attorney:
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 criggerj@etsu.edu
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:
https://www.etsu.edu/bf/documents/employeevscontractor.pdf
