OLD FORM do not use.
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Departmental Request for Performance/ Services Agreement
Contract Administration
650.2439 � MS 1420

#New Form
Section I: Contract Details
Description of Services (include specific deliverables along with any criteria/specifications, and specific
due dates):
Date(s) of Service:
Place of Performance/Services:
Payment Amount (made following completion of performance or service):  
  Note: a completed and signed IRS Form W-9 or W-9 substitute form will be required (sent to contractor by university contracts).
Additional Items:
Special Conditions:
Last Name:

First Name:

Physical Mailing Address:
Is this person a current or past Western student or employee?   If yes, W#:
Section II: Contract Requestor Information
(In case additional details are required)
Name of requestor:
Section III: Requesting Department/Program/Office
(Authorizing contract; will be contact for any other correspondence/copies/communications)
Requesting office contact name:
Purchase Form number to be billed:  
Routing Instructions
bullet Requester to Submit form to Contract Administration
bullet Upon approval,  Contract Administration to Approve form to Accounts Payable
bullet Accounts Payable to Approve or Disapprove and Lock form
The submitter may optionally enter their email address below. Press SUBMIT to send it.