 |
Guest/Special Lecture
Invoice C-710
|
|
|
Guest/Special Lecture
Invoice C-710
|
|
To: |
From: |
|
California
State University, Northridge |
Full
Name: |
|
Attn:
Accounts Payable |
Address:
|
|
18111
Nordhoff Street |
City,
State, Zip: |
|
Northridge,
CA 91330-8202 |
Phone: |
|
Last 4 digits SSN: |
||
Topic
of Lecture:
|
||
Date(s)
of Lecture:
|
Amount
of Payment: $ |
|
I. Residency
Status:
(Mandatory - Check one only) |
||
U.S. Citizen |
Permanent Resident Alien (Green-card Holder) |
Foreign National |
Please Provide your Vendor Data Record: http://www.calstate.edu/CSP/crl/forms/CRL040.pdf |
||
|
WAIVER & RELEASE |
I
UNDERSTAND AND ACKNOWLEDGE THAT AS A CONDITION PRECEDENT TO PERFORMING
THIS SERVICE: |
I
AM WORKING AS AN INDEPENDENT CONTRACTOR AND NOT AS AN EMPLOYEE OF CALIFORNIA
STATE UNIVERSITY, AND I AM SOLELY RESPONSIBLE FOR ANY AND ALL TAXES, COSTS,
INTEREST, ASSESSMENTS, PENALTIES, DAMAGE, ATTORNEY'S FEES, OR OTHER COSTS
WHICH MAY ARISE FROM THE PERFORMANCE OF THIS SERVICE. |
I
DO HEREBY WAIVE, PERSONALLY RELEASE, HOLD HARMLESS AND FOREVER DISCHARGE
ANY AND ALL CLAIMS FOR DAMAGES FOR PERSONAL INJURY, INCLUDING DEATH, OR
PROPERTY DAMAGE WHICH I MAY HAVE, OR WHICH MAY HEREAFTER ACCRUE TO ME,
AGAINST THE CALIFORNIA STATE UNIVERSITY (UNIVERSITY) AS A RESULT OF MY
PERFORMANCE OF THIS SERVICE. |
THIS
RELEASE IS INTENDED TO DISCHARGE THE STATE OF CALIFORNIA; THE TRUSTEES
OF THE CALIFORNIA STATE UNIVERSITY; CALIFORNIA STATE UNIVERSITY, NORTHRIDGE;
ITS AUXILIARY ORGANIZATIONS, AND THEIR OFFICERS, AGENTS, EMPLOYEES, AND
VOLUNTEERS FROM AND AGAINST ANY AND ALL CLAIMS ARISING OUT OF OR CONNECTED
N ANY WAY WITH MY PARTICIPATION IN THE SERVICE OUTLINED ABOVE. |
I
HAVE READ THIS FORM, AND UNDERSTANDING THE TERMS IN IT, I ALSO UNDERSTAND
THAT BY SIGNING THIS DOCUMENT, I MAY BE GIVING UP LEGAL RIGHTS WHICH I,
OR OTHERS CLAIMING THROUGH ME, MAY HAVE NOW OR IN THE FUTURE. IT IS FURTHER
UNDERSTOOD AND AGREED THAT THIS WAIVER, RELEASE AND ASSUMPTION OF RISK
IS TO BE BINDING ON MY HEIRS AND ASSIGNS. |
|
Lecturer
Signature: ____________________________________________
|
Date: _________________
|
II. Departmental
Certification / Approval: |
|
I
certify that the above indicated lecture was performed as agreed and herein
authorize payment of this invoice: |
|
Approved
By:
|
|
| Original
Signature: _____________________________________ (Facsimile Stamp Not Accepted) |
Date: ____________ |
Contracting Department: |
Tel No: |
|
For
Dept Use Only |
|||||||
| * REQUIRED: |
*
ACCOUNT: |
*
FUND: |
*DEPT
ID: |
*PROGRAM:
|
CLASS: |
PROJECT/GRANT:
|
REQ NO: |
|
|
|
|
|
|
|
||