Consulting AgreementAmendment Request Form

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					                                    Consulting Agreement/Amendment Request Form

To:
From:


Re:      Consulting Agreement/Amendment Request
Date: Wednesday, December 10, 2008

Note: Please complete all items in this memo and return with attachments to my attention for processing.
Appendices must be typed attachments. Once the consulting agreement/amendment is complete it will be
returned for your review before forwarding for execution.

1.     Project ID

2.     Indicate type of document:         New Agreement            Amendment to existing Agreement
       If this is a modification, please explain what in the original consulting agreement needs to be
3.
       modified.



       Name of the Consultant
4.
5.     Period of performance for the agreement                     From:                    To:

6.    Contact information for the                      Name:                      Title:
      Consultant
                                                       Address:


                                                       Telephone:                Fax:
                                                       Email:
7.     Contact information for                          Name:                      Title:
       Consultant - Contract
                                                        Address:
       Administrator

                                                        Telephone:                Fax:
                                                        Email:

8.     To whom should FIU mail the                      Name:                     Title:
       completed Consulting
                                                        Address:
       Agreement?

                                                        Telephone:                 Fax:
                                                        Email:

9.     Statement of work for the Consultant (please attach typed statement of work as Appendix A)
D:\Docstoc\Working\pdf\7b0d1a21-8a50-4595-9e1f-4b7125f83543.doc                                      12/10/2008
10. Budget or deliverable schedule for the Consultant work (please attach budget as Appendix B)
11. Termination Notice 30 or 60 days?
12. Consultant Agreement above 50K requires a Bid Exemption Certification (form online at
    www.osra.fiu.edu)
13. Conflict of Interest: Are there any existing or potential financial and/or other conflicts of interest
    with the consultant or the entity or the person with which FIU will be contracting? Or is there any
    relationship between the consultant or the person or the entity with which FIU will be contracting?
            Yes        No
       If YES, FIU employee(s) must complete the applicable Faculty Outside Activities and Financial
       Interest Report available at http://academic.fiu.edu/AcademicBudget/www/downloadforms.htm or
       the A&P/USPS Report of Outside Activities form available at
       http://www.fiu.edu/hr/formslibrary/records/outside_activity.pdf before the subcontract is prepared
       or signed.
       To view FIU’s policy statements regarding conflicts of interest please visit:
       http://policies.fiu.edu/record_profile.php?id=106, http://policies.fiu.edu/record_profile.php?id=399,
       http://policies.fiu.edu/record_profile.php?id=285.
 14. IRB or IACUC Approvals: Will there be any Human Subjects (including surveys) and/or Animal
     Use study done at the Subcontractor’s site? Yes No
 15. Previously Executed Agreements: Is this consulting agreement related to a previously executed
     Non-Disclosure or Proprietary Information Agreement.    Yes     No


PI Signature: ___________________________________                     Date: __________________

Name (typed):
Phone:
Fax:




                                                       FOR OSRA USE ONLY
       Restricted Parties Search (RPS) completed on:              ___________/_______________/____________
       RPS results attached to this memo.

OSRA Representative Signature: ______________________________ Date: _______________________




D:\Docstoc\Working\pdf\7b0d1a21-8a50-4595-9e1f-4b7125f83543.doc                                      12/10/2008

				
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