Appendix To Rule 0620-03-02-.01 − Form

MEMORANDUM OF AGREEMENT FOR EMPLOYEE SERVICES (Dual Services) _____________________________________ ____________________________________ Vendor Agency Procuring Agency THIS MEMORANDUM signifies agreement of the above parties concerning the provision of employee services. The agreement is as follows: 1. Vendor Agency agrees to furnish the services of its employee _____________________________________________________________, Social Security No. ________________________________, who will perform the following services for Procuring Agency: ____________________________________________________________________________________ ____________________________________________ POLICY AND PROCEDURES REGARDING THE PERFORMANCE OF CHAPTER 0620-03-02 SERVICES BY A STATE EMPLOYEE FOR A STATE AGENCY OTHER THAN THE ONE BY WHICH HE IS EMPLOYED 2. Compensation to employee $__________ (payable through Vendor’s personnel system by supplemental pay authorization). Reimbursement by Procuring Agency to Vendor Agency (includes cost of any applicable staff benefits to Vendor’s employee for service under this agreement) $__________. 3. Payment will be made by Procuring Agency after completion of service and after receipt of invoice from Vendor Agency, mailed to the following address: _______________________________________________ _______________________________________________ _______________________________________________ _______________________________________________ 4. Term: ________________________________________________________________________________ Dated This ______________________ day of ________________________, 19________. (Vendor Agency) (Procuring Agency) By: __________________________________ By:____________________________________ Title: _________________________________ Title: __________________________________ *Department of Finance and Administration By: ________________________________________ *This approval necessary only if compensation to the Vendor’s employee is to exceed $1,500.