A. Name
and Address Complete name and address of vendor
B. Location Huntington, WV 25755
C. Description of Service; These 4 lines
are reserved for a description of the work
or service to be performed.
D. Date of Service The date the service
is to be performed should be entered. If the
service is to extend over a long period of time, enter the beginning
date and the final
date of service. Be sure that the agreement does not commit appropriated
funds in future fiscal years.
E/F. Rate of Pay Enter the rate of pay as the total amount
per day, month, or year
G. Not to Exceed Enter the total amount of
the fee for the services, including
anticipated travel
H. Please check appropriate box If the
agreement is with an individual, the appropriate
box under this section must be clearly checked
I. Social Security/FEIN Enter the
vendor's social security number or FEIN
J. Vendor's signature The signature of
the individual or officer of company performing
the services must be indicated in this space
K. Date The date of signature by
the vendor
L. This section must be completed
for any individual who is a full time employee
of the State of West Virginia. Compensation must be shown as the
annual salary. A dean or higher level administrator must sign the certification
statement.
Note:
The signed agreement and requisition must reach Purchasing 45 days prior
to the start of services.
One John Marshall Drive, Old Main 108, Huntington, West Virginia
25755-4100
Ph: 304.696.3157
Fx: 304.696.3333
