Faculty Handbook Form 2.07 A

FORMAT FOR MEMO ON CONSULTING SERVICE

(For use by faculty who are interested in consulting with an external agency.

Please use departmental stationery.)

TO: Department Chair or Individual Supervisor

FROM:

RE: Individual Consulting for Compensation with Agency or Organization

It is my intent to provide for compensation the following services:
_____________________________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________

To: (List name of company or agency. State in general terms if confidentiality is an issue.)_____________________________________________________________________________

The time period will be from __________________________ to _________________________

The use of personnel, materials, and/or services of Georgia College & State University will be compensated in the following manner:
_____________________________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________

To my knowledge, there is no conflict of interest with my assigned duties at Georgia College & State University.

______________________________________

Individual’s Signature

Approved:

________________________________________________________

Department Chair or Supervisor Date

________________________________________________________

School Dean Date

Attachment(s): a) Outline of educational services if two or more persons are
to receive training.

b) Budget information if university resources are to be used.

cc: Dean, Extended University,

Research and Graduate Services ____________________________________

Initials and Date

(School dean forwards to Dean of Extended University upon approval.)