CSU CHANNEL ISLANDS ~ AGREEMENT ROUTING FO
RM
Attach this routing form to all agreements or contracts
REQUES
T FOR FINAL SIGNATURE MUST BE MADE 14 CALENDAR DAYS PRIOR TO AGREEMENT START DATE.
Vendor/Contracting Agency Name: Phone:
Vendor/Agency Contact: Fax:
Agreement Transaction Amount: Term Start Date: Term End Date:
New Standard Amendment* Change Order* MOU/MOA Student Placement
Service Agreement ESA TOSA JOC Lease
Publi
c Works Agreement Project Architect/Engineer Agreement Interagency Agreement
Grant Other
*
If
this
is
an
amendment
or
change
order,
please
provide
Original Agreement number:
Agreement
Purpose/Summary:
Special Instructions:
Verification of Agreement Components
INDICATE Yes, No, N/A
Agreement contains scope of work and maximum dollar limit (including miscellaneous
expenses)
Yes No N/A
Price and rates are in accordance with law, policies and guidelines
Yes No N/A
RFP/IFB # or Statutory Authority reference, as applicable
Yes No N/A
Specific Payment Schedule & Instructions are included
Yes No N/A
Effective Date of Agreement & Ending Date of Agreement are specified
Yes No N/A
W-9 or 204 Form completed by Vendor is on file w/ PCS Office?
Yes No N/A
General Provisions are attached if needed
Yes No N/A
Insurance Provisions, Requirements and Indemnification (Requires CSU Standards or
Yes No N/A
FOR DFA INTERNAL USE ONLY
Return Fully Executed Agreement to: Phone:
Reviewers (line out those not needed)
Date
Received
Reviewer Initials
Date
Forward
ed
Vendor/Entity Agreement Received
Required on Agreement
//////////////
Buyer, Procurement & Contract Services
Risk Manager
Director, Procurement & Contract Services
Vice President or Designee (Transactions of $100K or more, MOUs,
President (Transactions of $300K or more)
INTERNAL DOCUMENT C.I. AGREEMENT ROUTING FORM 2/2013
Date:
Dept. Originating Agreement:
PO Number #
(Will be assigned by PCS)
Originating Dept. Contact: Phone:
