Short Term Limited Scope Service (STLS)
Agreement and Express Invoice
Use only for services up to $5,000.00 provided by an individual/sole proprietor.
If services costs more than $5,000.00, please have the department enter a requisition.
For use for the following services only, check appropriate box:
Participant (FOR GRANT USE ONLY)Accompanists
Referee
Sign Language Interpreter
Art Model Guest Artist/Lecturer Honorarium
Note taker
Payee Information:
Name:
Address:
City, State, Zip:
Vendor Data Record Form:
On File Attached
Tax Payor ID # or Last 4 digits of SSN # :
Department Name:
Department Contact:
Contact Phone #:
Check Delivery Instructions:
Mail to Payee
Pick up at
Cashier's Office
Account Fund Dept. ID Program Class Project/Grant*** Total Due:
$
Brief Description of Service:
RELEASE OF LIABILITY: For the aforementioned services, I assume all liability for any damage or injuries accruing thereof, and that further, in consideration for being
allowed to provide this service hereafter referred to as the Activity, I release from liability and waive my right to sue the State of California, the Trustees of the California State
University, and which own and operate California State University, East Bay and their employees, officers, volunteers and agents (collectively "University") from any and all
claims, including illness, injuries, death or economic loss that I may suffer because of my involvement in this Activity, including any travel to and from the Activity. I will hold
the University harmless from any and all claims, loss or damage to my personal property, liabilities and costs, including attorney's fees, as a result of my involvement in this
Activity. It is further agreed that this waiver, release, and assumption of risk is to be binding on my heirs and assigns.
I understand that this document is written to be as broad and inclusive as legally permitted by the State of California. I agree that if any portion is held invalid or
unenforceable, I will continue to be bound by the remaining items.
Name: Date:
Signature:
This is the sole binding contract for this service with the University; other contractual documents will not be accepted.
I certify that the vendor is acting in an independent capacity and not as an officer or employee or agent of the State of California. I also certify that the
above services have been satisfactorily performed or are to be performed as stated.
Approval of authorized individual such as Department Chair,
Dean, etc.
Date Purchasing Review Date
A&F Finance, April 2017
Proof of Auto Insurance:
Drove to University**
Did not drive to University
**A PROOF OF VALID/CURRENT AUTO INSURANCE IS REQUIRED
TO PROTECT THE UNIVERSITY FROM ANY LIABILITY.
Student (For Accounts Payable purposes)
ATTENTION: IF YOU ARE A UNIVERSITY EMPLOYEE, YOU MAY NOT USE THIS FORM. PLEASE SEE PAYROLL INSTEAD.
Date Needed:
Photographer/Videographer
Lives on Campus
Does not provide this service as primary function for coming to Campus
Used Public Transportation
Other:
Date of Service: Total Hours of Service:
*** Please attach multiple cost lines on a separate sheet.
*NO PAYMENT WILL BE ISSUED WITHOUT A COMPLETED VDR.
