Business Services Agreement Form If you have any questions about this form, contact Mike Heaton at 785-864-1646 or firstname.lastname@example.org. PERSON COMPLETING THIS FORM: Name * First and last name Phone * Email * CONTRACTOR INFORMATION: Contractor's Name * First and last name Contractor's Contact Person * First and last name Contractor's Address* Contractor's Address * City * State * Zipcode * Contractor's Phone * Contractor's Email * PROJECT INFORMATION: Project ID/Funding Source(s) * Please provide each source of funding with the percentage of the total. The percentages should add up to 100%. Funding Source * Name of Funding Source Percent of total * % % of total Additional Funding Sources Additional Funding Source 1 Report Second Percent of total % % of total Additional Funding Source 2 Report Third Percent of total % % of total Additional Funding Source 3 Report Fourth Percent of total % % of total Additional Funding Source 4 Report Fifth Percent of total % % of total Administration Department * Principal Investigator's Name * First and last name Principal Investigator's Address* Pi's Address * PI's City * Pi's State * PI's Zipcode * Principal Investigator's Email * Principal Investigator's Phone * DEAL POINTS: Scope of Services: Please attach a document detailing the services to be provided.* Scope of service document * Word or PDF document- max. size 2 MBFiles must be less than 2 MB.Allowed file types: pdf doc docx. Terms of Services: Starting* TOS Starting: * Year Year201720182019 Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Ending* TOS End Date * Year Year201720182019202020212022202320242025202620272028 Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Cost of Services (US Dollars) * $ If total cost is unavailable, please estimate. Special Payment Terms (if any) Justification: If cost of services is > $3,000.00, please attach either: a) At least two other quotes from comparable providers: or b) A sole source justification explaining why contractor is the ONLY source for the services. Justification documentation Word or PDF document- max. size 2 MBFiles must be less than 2 MB.Allowed file types: pdf doc docx. Additional Comments or Notes of Importance CAPTCHAThis question is for testing whether or not you are a human visitor and to prevent automated spam submissions. What code is in the image? * Enter the characters shown in the image.