This Form Is to Be Filled out by Contractor and the Requesting Campus/Department

REQUEST FOR INDEPENDENT CONTRACTOR SERVICES FORM

(This form is to be filled out by contractor and the requesting campus/department)

CONTRACTOR INFORMATION: To be filled out by contractor
Contractor is an: / Individual/Sole Proprietor / Corporation / Partnership

Name:

(name as appears in Box 1 of W-9)

Address:

(number, street, apt. or suite no.)

City / State / ZIP Code:

If Business, provide business information below:

Business Name:

(nameas appears in Box 2 of W-9)

Business Address:

(number, street, apt. or suite no.)

Business City / State / ZIP Code:

Phone: Cell:

Email: Fax:

Additional Company Representatives (list first and last name):

License or Certification:

Contractor SignaturePrint NameDate

CAMPUS/DEPT INFORMATION: To be filled out by requesting campus/dept

Campus / Department:

Contact Name:

Email:

Phone: Fax:

Contractor will be presenting to: / Students
Only / Staff Only / Students & Staff / Other

If other, must provide details:

Contracted Services to be provided(list specific services to be provided by contractor):

Campus or District Locationswhere services will take place:

Length of Service to be covered by this contract: / Start Date: / End Date:
COMPENSATION: To be filled out by requesting campus/dept

Check one:Total Amount

PER HOUR, RATE OF$ for hours

PER DAY, RATE OF$ for days

PER MONTH, RATE OF$ for months

OTHER, RATE OF$ Frequency and duration of services

If other, must provide details:

Does Total Compensation include Reimbursable Costs? Yes No

If yes, the contractor requires reimbursement for costs (e.g. air travel, lodging, transportation, meals, per diem, handouts, and all other District authorized expenses) associated with the services provided, the Contractor must identify this requirement below. For contractors requiring reimbursement, receipts are required and the District will only pay the actual costs incurred by the contractor.

Estimated Cost

Airline Tickets: $

Lodging:$

Mileage: $

Rental Car: $

Meals:$

Parking:$

Other:$

Total$

Does Total Compensation Amount Exceed $2,000.00 annually? Yes No

If yes, fill out the Contractor Evaluationsection below. The purpose of providing this information is to assist the Purchasing Deptin determining compliance with governing purchasing laws, regulations and board policies.Questions - contact the Purchasing Dept at 817-232-0880, ext. 2977.

Contractor Evaluation

List companies considered and evaluated (include name and location):

(Must provide a minimum of three companies)

List of qualifications for companies considered.

Pricing from companies considered.

Estimated annual expenditures under this contract: $

REQUIRED SIGNATURE:

Campus Principal / Department Director / Chief Officer:

SignaturePrint NameDate

Page 1 of 2REVISED: 12/15/2015