UNIVERSITY SYSTEM EMPLOYEES
EMPLOYMENT COMPENSATION AGREEMENT
BETWEEN INSTITUTIONS
__________________________________________
1. REQUESTING INSTITUTION
PROVIDING INSTITUTION__________________________________________
2. REQUESTING INSTITUTION’S NEED for and description of services to be performed (attach additional sheets if necessary).
3. REQUESTING INSTITUTION’S JUSTIFICATION for obtaining part-time services from another University System employee in lieu of obtaining such
services from a person not presently employed by the University System (attach additional sheets if necessary).
4. EMPLOYEE’S CERTIFICATION: Employee to perform services as (mark one):
NAME
Chaplain Fireman Dentist
Registered Nurse Licensed Practical Nurse
Licensed Physician Psychologist
SOCIAL SECURITY #
Certified Oral or Manual Interpreter for Deaf Persons
EMPLOYED BY
Teacher or Instructor of an evening or night course or program
EMPLOYEE’S SIGNATURE
Professional holding a doctoral or masters degree from a
DATE
accredited college or university
5. MEANS OF PAYMENT :
Requesting institution pays Providing Institution
Requesting institution pays Individual
6. METHOD OF PAYMENT: Subject to performance of services and approval of an invoice, payment will be made via the institution’s normal processing
channels. Payment for employees will be made to the providing institution, which will pay excess compensation to the employee. Payment for consultants
will be made to consultant directly, unless other arrangements are made.
Account Number
Fee for Service
Estimated Reimbursable Expense
Total Estimated Cost
Projected Dates of Service
Payee (Institution or Individual)
7. CONTACT INFORMATION:
REQUESTING INSTITUTION
PROVIDING INSTITUTION
Name:
Name:
Phone:
Phone:
E-mail:
E-mail:
8. PROVIDING INSTITUTIONS CERTIFICATION OF AVAILABILITY OF EMPLOYEE:
I certify that the above person is available to perform the described services and that the performance of these services will not detract from nor have a
detrimental effect on the performance of the person’s employment at our institution.
Employee’s Dean/Department Head Date
9. APPROVED BY:
President, Providing Institution Date
President, Requesting Institution Date
