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Guest/Special Lecture
Invoice C-710
UNIVERSITY ACCOUNTS PAYABLE
TEL NO: (818) 677-3472
FAX NO: (818) 677-4581
MAIL DROP: 8202
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To: From:
California State University, Northridge Full Name:
Attn: Accounts Payable Address:
18111 Nordhoff Street City, State, Zip:
Northridge, CA 91330-8202 SSN:
Topic of Lecture:
Date(s) of Lecture: Amount of Payment: $
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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
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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.
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Lecturer Signature: ____________________________________________
Date: _________________
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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:


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*DEPT ID:
*PROGRAM:
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