UNIVERSITY SYSTEM EMPLOYEES
CONSULTANT SERVICES 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
Social Security # ___L icensed Physician ___ Psychologist
Employed by ___Certified Oral or Manual Interpreter for Deaf Person
Employee’s Signature ___Teacher or Instructor of an evening or night course or program
Date ___Professional holding a doctoral or masters degree from an
accredited college or university
5. EMPLOYEE CLASSIFICATION / 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 administer extra compensation to the employee.
Payment for consultants will be made to consultant directly, unless other arrangements are made. An Employee/Indepdent Contractor
Determination Checklist must be attached to this form to determine appropriate classification. Travel reimbursements to both
employees and consultants will be made by the requesting institution.
Account Number
Fee for Service
Estimated Reimbursable Expense
Total Estimated Cost
Projected Dates of Service
Payee (Institution or Individual)
6. PROVIDING INSTITUTION’S 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.
etaDdaeH tnemtrapeD/naeD s’eeyolpmE
7. APPROVED BY:
President, Providing Institution Date
President, Requesting Institution Date
Part-time Employee Consultant
ROUTING: For USG employees paid as consultants: Attach this form to all associated check requests.
For USG employees to be paid as employees (thru payroll): Route this form to the Payor Institution’s Payroll Department.
