CSU Services and Honorarium Request Form

Connecticut State University System
Services and Honorarium Request Form
(must be $3,000 or less)
ORIGINAL
1. The University and the Service Provider as listed below hereby enter into an agreement subject to the terms
and conditions stated herein and/or attached hereto and subject to the provisions of section 4-98 of the
AMENDMENT
Connecticut General Statutes as applicable.
2. Acceptance of this agreement implies conformance with terms and conditions set forth at sheet 2 of this
AMENDMENT #
file, as attached hereto and incorporated by reference.
3. If a service provider will be paid more than $3,000 in any rolling 12-month period, a PSA form CO-802A must
be prepared and approved in advance of the start date of the service.
SERVICE PROVIDER
Under no circumstances are any services to be performed under this agreement unless the Project Director has received approval.
1.
2.
3.
LEAVE BLANK
FEIN/SSN:
SERVICE PROVIDER E-MAIL ADDRESS:
Yes
ARE YOU CURRENTLY A STATE EMPLOYEE?
No
IF YOU ANSWERED YES TO NUMBER 3 ABOVE, A DUAL EMPLOYMENT FORM MUST BE COMPLETED AND MADE PART OF THIS AGREEMENT
4.
DO YOU HAVE AN IMMEDIATE FAMILY MEMBER WHO IS A STATE EMPLOYEE?
Yes
No
5.
HAVE YOU CONTRACTED WITH THIS UNIVERSITY ANYTIME DURING THE PAST 12 MONTHS?
Yes
No
6.
BOARD OF TRUSTEES FOR CONNECTICUT STATE UNIVERSITY/SOUTHERN CONNECTICUT STATE UNIVERSITY, 501 CRESCENT ST., NEW HAVEN, CT 06515-1355
7.
UNIVERSITY
SERVICE PROVIDER
NAME:
SERVICE PROVIDER
ADDRESS:
SERVICE PROVIDER
PHONE:
TELEPHONE NUMBER:
PROJECT DIRECTOR'S NAME:
***PROJECT DIRECTORS MUST COMPLETE THE " Independent Contractor or Employee Preliminary Determination Questionnaire". NOTE:NEITHER GUEST SPEAKERS NOR COMPANIES REQUIRE A
QUESTIONNAIRE. IF NUMBERS 3 AND/OR 4 ABOVE WERE ANSWERED "YES" AND THE CONTRACT VALUE OF THIS AGREEMENT IS EQUAL TO OR GREATER THAN $100, AND IS TO BE PAID AS AN
INDEPENDENT CONTRACTOR, THIS CONTRACT MUST HAVE BEEN AWARDED THROUGH AN OPEN AND PUBLIC PROCESS. BIDDING SATISFIES THIS REQUIREMENT.
8.
BANNER:
BANNER:
_____-_________- 721120 - __________
_____-_________- 721120 - __________
10. SERVICE PERIOD:
11.
FROM: ________________
AUTHORIZED FUNDING SIGNATURE:
AUTHORIZED FUNDING SIGNATURE:
$
TOTAL AMOUNT OF THIS DOCUMENT:
9.
AMOUNT: $
AMOUNT: $
GRANT FUNDING SIGNATURE:
TO: ________________
CONTRACT BID AWARD # IF APPLICABLE: _______________
days
THIS AGREEMENT SHALL REMAIN IN FULL FORCE AND EFFECT FOR THE ENTIRE TERM OF THE SERVICE PERIOD STATED ABOVE UNLESS CANCELLED
BY THE UNIVERSITY, BY GIVING THE SERVICE PROVIDER WRITTEN NOTICE OF SUCH INTENTION. (REQUIRED DAYS NOTICE SPECIFIED AT LEFT).
13. TOTAL AGREEMENT NOT TO EXCEED:
$_________________
(ORIGINAL AGREEMENT AMOUNT + ALL AMENDMENTS).
14. PAYMENT TO BE MADE UNDER THE FOLLOWING SCHEDULE:
ACCEPTANCES/APPROVALS
TERMS AND CONDITIONS
12. THE SERVICE PROVIDER AGREES TO: (DETAILED SERVICES MUST BE PROVIDED ALONG WITH SPECIAL PROVISIONS AS NECESSARY.)
Version 11/08
STATUTORY AUTHORITY CGS 10a-151b
SERVICE PROVIDER (OWNER OR AUTHORIZED SIGNATURE):
TITLE:
DATE:
TITLE:
DATE:
(Required if fee is greater than $600)
UNIVERSITY OFFICIAL (AUTHORIZED SIGNATURE):
(Required if fee is greater than $600)
DOCUMENT NUMBER:
ENCUMBERED (DATE & INITIALS
TERMS/CONDITIONS
EXECUTIVE ORDERS
The contract is subject to the provisions of Executive Order No. 7C of Governor M. Jodi Rell, promulgated July 13, 2006, concerning contracting reforms, Executive
Order No. 14 of Governor M. Jodi Rell, promulgated April 17, 2006, concerning procurement of cleaning products and services, Executive Order No. 16 of Governor
John G. Rowland, promulgated August 4, 1999, concerning violence in the workplace, Executive Order No. 17 of Governor Thomas J. Meskill, promulgated February
15, 1973, concerning the listing of employment openings and Executive Order No. 3 of Governor Thomas J. Meskill, promulgated June 16, 1971, concerning labor
employment practices, all of which are incorporated into and are made a part of the Contract as if they had been fully set forth in it. At the Contractor’s request, the
Client Agency shall provide a copy of these orders to the Contractor.
CAMPAIGN CONTRIBUTION RESTRICTIONS
On February 8, 2007, Governor Rell signed into law Public Act 07-1, An Act Concerning the State Contractor Contribution Ban and Gifts to State and Quasi-Public
Agencies. For all State contracts as defined in P.A. 07-1 having a value in a calendar year of $50,000 or more or a combination or a series of such agreements or
contracts having a value of $100,000 or more, the authorized signatory to this Agreement expressly acknowledges receipt of the State Elections Enforcement
Commission’s notice advising state contractors of state campaign contribution and solicitation prohibitions, and will inform its principals of the contents of the notice.
See SEEC Form 11.
NON-DISCRIMINATION
(a) For purposes of this Section, the following terms are defined as follows:
i. “Commission" means the Commission on Human Rights and Opportunities;
ii. "Contract" and “contract” include any extension or modification of the Contract or contract;
iii. "Contractor" and “contractor” include any successors or assigns of the Contractor or contractor;
iv. "Gender identity or expression" means a person's gender-related identity, appearance or behavior, whether or not that gender-related identity, appearance or
behavior is different from that traditionally associated with the person's physiology or assigned sex at birth, which gender-related identity can be shown by providing
evidence including, but not limited to, medical history, care or treatment of the gender-related identity, consistent and uniform assertion of the gender-related identity
or any other evidence that the gender-related identity is sincerely held, part of a person's core identity or not being asserted for an improper purpose.
v. “good faith" means that degree of diligence which a reasonable person would exercise in the performance of legal duties and obligations;
vi. "good faith efforts" shall include, but not be limited to, those reasonable initial efforts necessary to comply with statutory or regulatory requirements and additional
or substituted efforts when it is determined that such initial efforts will not be sufficient to comply with such requirements;
vii. "marital status" means being single, married as recognized by the State of Connecticut, widowed, separated or divorced;
viii. "mental disability" means one or more mental disorders, as defined in the most recent edition of the American Psychiatric Association's "Diagnostic and
Statistical Manual of Mental Disorders", or a record of or regarding a person as having one or more such disorders;
ix. "minority business enterprise" means any small contractor or supplier of materials fifty-one percent or more of the capital stock, if any, or assets of which is
owned by a person or persons: (1) who are active in the daily affairs of the enterprise, (2) who have the power to direct the management and policies of the enterprise,
and (3) who are members of a minority, as such term is defined in subsection (a) of Connecticut General Statutes § 32-9n; and
x. "public works contract" means any agreement between any individual, firm or corporation and the State or any political subdivision of the State other than a
municipality for construction, rehabilitation, conversion, extension, demolition or repair of a public building, highway or other changes or improvements in real
property, or which is financed in whole or in part by the State, including, but not limited to, matching expenditures, grants, loans, insurance or guarantees.
For purposes of this Section, the terms "Contract" and “contract” do not include a contract where each contractor is (1) a political subdivision of the state, including,
but not limited to, a municipality, (2) a quasi-public agency, as defined in Conn. Gen. Stat. Section 1-120, (3) any other state, including but not limited to any federally
recognized Indian tribal governments, as defined in Conn. Gen. Stat. Section 1-267, (4) the federal government, (5) a foreign government, or (6) an agency of a
subdivision, agency, state or government described in the immediately preceding enumerated items (1), (2), (3), (4) or (5).
(b) (1) The Contractor agrees and warrants that in the performance of the Contract such Contractor will not discriminate or permit discrimination against any person
or group of persons on the grounds of race, color, religious creed, age, marital status, national origin, ancestry, sex, gender identity or expression, mental retardation,
mental disability or physical disability, including, but not limited to, blindness, unless it is shown by such Contractor that such disability prevents performance of the
work involved, in any manner prohibited by the laws of the United States or of the State of Connecticut; and the Contractor further agrees to take affirmative action to
insure that applicants with job-related qualifications are employed and that employees are treated when employed without regard to their race, color, religious creed,
age, marital status, national origin, ancestry, sex, gender identity or expression, mental retardation, mental disability or physical disability, including, but not limited
to, blindness, unless it is shown by the Contractor that such disability prevents performance of the work involved; (2) the Contractor agrees, in all solicitations or
advertisements for employees placed by or on behalf of the Contractor, to state that it is an "affirmative action-equal opportunity employer" in accordance with
regulations adopted by the Commission; (3) the Contractor agrees to provide each labor union or representative of workers with which the Contractor has a collective
bargaining Agreement or other contract or understanding and each vendor with which the Contractor has a contract or understanding, a notice to be provided by the
Commission, advising the labor union or workers’ representative of the Contractor's commitments under this section and to post copies of the notice in conspicuous
places available to employees and applicants for employment; (4) the Contractor agrees to comply with each provision of this Section and Connecticut General
Statutes §§ 46a-68e and 46a-68f and with each regulation or relevant order issued by said Commission pursuant to Connecticut General Statutes §§ 46a-56, 46a-68e
and 46a-68f; and (5) the Contractor agrees to provide the Commission on Human Rights and Opportunities with such information requested by the Commission, and
permit access to pertinent books, records and accounts, concerning the employment practices and procedures of the Contractor as relate to the provisions of this
Section and Connecticut General Statutes § 46a-56. If the contract is a public works contract, the Contractor agrees and warrants that he will make good faith efforts
to employ minority business enterprises as subcontractors and suppliers of materials on such public works projects.
(c) Determination of the Contractor's good faith efforts shall include, but shall not be limited to, the following factors: The Contractor's employment and
subcontracting policies, patterns and practices; affirmative advertising, recruitment and training; technical assistance activities and such other reasonable activities or
efforts as the Commission may prescribe that are designed to ensure the participation of minority business enterprises in public works projects.
(d) The Contractor shall develop and maintain adequate documentation, in a manner prescribed by the Commission, of its good faith efforts.
(e) The Contractor shall include the provisions of subsection (b) of this Section in every subcontract or purchase order entered into in order to fulfill any obligation
of a contract with the State and such provisions shall be binding on a subcontractor, vendor or manufacturer unless exempted by regulations or orders of the
Commission. The Contractor shall take such action with respect to any such subcontract or purchase order as the Commission may direct as a means of enforcing
such provisions including sanctions for noncompliance in accordance with Connecticut General Statutes §46a-56; provided if such Contractor becomes involved in, or
is threatened with, litigation with a subcontractor or vendor as a result of such direction by the Commission, the Contractor may request the State of Connecticut to
enter into any such litigation or negotiation prior thereto to protect the interests of the State and the State may so enter.
(f) The Contractor agrees to comply with the regulations referred to in this Section as they exist on the date of this Contract and as they may be adopted or amended
from time to time during the term of this Contract and any amendments thereto.
(g) (1) The Contractor agrees and warrants that in the performance of the Contract such Contractor will not discriminate or permit discrimination against any person
or group of persons on the grounds of sexual orientation, in any manner prohibited by the laws of the United States or the State of Connecticut, and that employees are
treated when employed without regard to their sexual orientation; (2) the Contractor agrees to provide each labor union or representative of workers with which such
Contractor has a collective bargaining Agreement or other contract or understanding and each vendor with which such Contractor has a contract or understanding, a
notice to be provided by the Commission on Human Rights and Opportunities advising the labor union or workers' representative of the Contractor's commitments
under this section, and to post copies of the notice in conspicuous places available to employees and applicants for employment; (3) the Contractor agrees to comply
with each provision of this section and with each regulation or relevant order issued by said Commission pursuant to Connecticut General Statutes § 46a-56; and
(4) the Contractor agrees to provide the Commission on Human Rights and Opportunities with such information requested by the Commission, and permit access to
2 pertinent books, records and accounts, concerning the employment practices and procedures of the Contractor which relate to the provisions of this Section and
Connecticut General Statutes § 46a-56.
(h)
The Contractor shall include the provisions of the foregoing paragraph in every subcontract or purchase order entered into in order to fulfill any obligation of a
contract with the State and such provisions shall be binding on a subcontractor, vendor or manufacturer unless exempted by regulations or orders of the Commission.
The Contractor shall take such action with respect to any such subcontract or purchase order as the Commission may direct as a means of enforcing such provisions
including sanctions for noncompliance in accordance with Connecticut General Statutes § 46a-56; provided, if such Contractor becomes involved in, or is threatened
with, litigation with a subcontractor or vendor as a result of such direction by the Commission, the Contractor may request the State of Connecticut to enter into any
such litigation or negotiation prior thereto to protect the interests of the State and the State may so enter.
INSURANCE/INDEMNIFICATION
The Contractor agrees that while performing services specified in this agreement he shall carry sufficient insurance (liability and/or other) as applicable according to
the nature of the service to be performed so as to “save harmless” the State of Connecticut for any insurable cause whatsoever. If requested, certificates of such
insurance shall be filed with the contracting State agency prior to the performance of services. Contractor hereby indemnifies and shall defend and hold harmless the
State, its officers and its employees from and against any and all suits, actions, legal or administrative proceedings, claims, demands, liabilities, monetary loss,
interest, attorneys fees, costs and expenses of whatsoever kind or nature arising out of the performance of this agreement, including those arising out of injury to or
death of Contractors employees or subcontractors, whether arising before, during or after completion of the services hereunder and in any manner directly or indirectly
caused, occasioned or contributed to in whole or in part by reason of any act, omission, fault or negligence of the Contractor or its employees, agents or
subcontractors.
STATE LIABILITY
The State of Connecticut shall assume no liability for payment for services under the terms of this agreement until the contractor is notified that this agreement has
been accepted by the contracting agency and, if applicable, approved by the Office of Policy and Management (OPM) or the Department of Administrative Services
(DAS) and by the Attorney General of the State of Connecticut.
GOVERNING LAW
The validity, construction and effect of this Agreement shall be governed by the laws of the State of Connecticut without regard to its principals of conflicts of laws,
and any question arising under this Agreement shall be construed or determined according to such laws, except to the extent preempted by federal law.
CLAIMS AGAINST THE STATE
The contractor agrees that the sole and exclusive means for the presentation of any claim against the State of Connecticut arising from this Agreement shall be in
accordance with Chapter 53 of the Connecticut General Statutes (Claims Against the State) and the contractor further agrees not to initiate legal proceedings in any
state or federal court in addition to, or in lieu or, said Chapter 53 proceedings.
ENTIRE AGREEMENT
This written Agreement shall constitute the entire agreement of the parties and no other terms and conditions in any document, acceptance or acknowledgement shall
be effective or binding unless expressly agreed to in writing by the State Agency. This agreement may not be changed other than by a formal written amendment
signed by the parties hereto.
SCSU 10/01/2011
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