EXHIBIT B
Section 330-05
Date: 11/16/98
Page 1 of 2
Date prepared:
BUSINESS AGREEMENT REQUEST AND DATA SHEET
(Campus departments; see page 2 for UCDHS departments)
Initiating department:
DaFIS
Org #
Department contact for information:
Phone:
Principal investigator (if applicable):
Phone:
Other party's name and mailing address:
Acct #
Does money need to be liened?
( ) Yes (notify Accounting Office)
( ) No
Are funds available?
( ) Yes
( ) Not presently (explain)
Extramural fund source (agency, contract/grant
title, and number):
Other party's Social Security # or Federal ID #:
Other party's contact for information:
Phone:
Has the other party provided a written contract or
purchase order?
( ) Yes, attached
( ) No
If the other party is a University employee, does he/she or a near relative propose to sell goods or provide
services to the University, or own or control more than 10% interest in the business that proposes to sell
goods or provide services to the University?
( ) Yes (refer to P&PM 350-90)
( ) No
DESCRIPTION OF AGREEMENT
Period of agreement:
Explain nature and purpose of agreement, including all relevant
details:
From______________ To_______________
( ) Expense
( ) Income
Amount______________________
Attach payment schedule if applicable.
If income, specify:
( ) Rate approved by Planning & Budget
( ) Budget attached
Location of property/site of work:
JUSTIFICATION
Describe how this work will benefit the University or relate to the University's mission of teaching,
research, and public service.
RELATED REQUIREMENTS
Does the initiating department require any additional space, personnel, or equipment to perform this work?
( ) Yes
If yes, explain how requirements will be met, and provide necessary additional approvals below.
( ) No
APPROVALS
Department head/designee
Date:
Dean or vice chancellor/designee
Date:
Planning & Budget (required for campus leased space
requests):
Name and title:
Date:
ADDITIONAL INFORMATION
Is a draft agreement attached?
( ) Yes
( ) No
Please attach any additional information necessary for an agreement to be written.
(Departments should copy this form as needed.
If necessary, use back of form or attach additional sheets.)
EXHIBIT B
Section 330-05
Date: 11/16/98
Page 2 of 2
Date prepared:
BUSINESS AGREEMENT REQUEST AND DATA SHEET
(UCDHS Departments)
Initiating department:
DaFIS Account Number
Are funds available?
( ) Yes
( ) Not presently (explain)
Department contact for information:
Phone:
Other party's name and mailing address:
Extramural fund source, if applicable (agency,
contract/grant title, and number):
Other party's Social Security # or Federal ID #:
Other party's contact for information:
Phone:
Has the other party provided a written contract
or purchase order?
( ) Yes, attached
( ) No
If the other party is a University employee, does he/she or a near relative propose to sell goods or provide
services to the University, or own or control more than 10% interest in the business that proposes to sell
goods or provide services to the University?
( ) Yes (refer to P&PM 350-90)
( ) No
DESCRIPTION OF AGREEMENT
Period of agreement:
Explain nature and purpose of agreement, including all relevant
details:
From______________ To_______________
( ) Expense
( ) Income
Amount______________________
Attach payment schedule if applicable.
If income, specify:
( ) Rate approved by _______________
( ) Budget attached
Location of property/site of work:
JUSTIFICATION
Describe how this work will benefit the University or relate to the University's mission of teaching,
research, public service, and patient care:
RELATED REQUIREMENTS
Are any materials being used that are toxic, explosive, radioactive, narcotic, or pathogenic?
( ) Yes If yes, provide Environmental Health & Safety approval: _________________________________________
( ) No
APPROVALS
UCDHS Chief Operating Officer/designee:
Date:
Department head/designee
Date:
Medical Sciences Planning (required for UCDHS leased
space requests):
Name and title:
Date:
ADDITIONAL INFORMATION
Please attach any additional information necessary for an agreement to be written or special factors of which
contract analyst should be aware.
(Departments should copy this form as needed.
If necessary, use back of form or attach additional sheets.