University of California at Berkeley 

EXPEDITED PROFESSIONAL SERVICES FORM 

Not to exceed $5,000.00   Name:  ______________________________________________________________________________  Address:  ________________________________ City: ________________ State: _____ Zip:_________ 

Country: ____________________________ 

Location where work will be performed:  Address:  _________________________________ City: ________________ State: _____ Zip: ________  Expected Payment Schedule:  ________________________  Total Amount to be Paid: ______________  

Description of Services to be Provided: 

       I _____________________________________shall indemnify and hold THE REGENTS OF THE UNIVERSITY OF CALIFORNIA, its officers, employees and agents harmless from and against any and all liability, loss, expense, including reasonable attorneys' fees, or claims for injury or damages arising out of the performance of this Agreement, but only in proportion to and to the extent such liability, loss, expense, attorneys' fees, or claims for injury or damages are caused by or result from the negligent or intentional acts or omissions of [_______________________________________], his/her officers, agents or employees.   Complete the Conflict of Interest Certification (Part A & B) attached  Signature of Provider:  ____________________________________________ 

Department Authorization:  _______________________________________________________ 

Prepared By:  __________________________________    Date:  _________________________  

[Note: This EPSF is for the professional service referenced above for this specific project only.  If additional services are rendered and increases the amount to exceed $5,000.00, the purchase order will be converted to a high value purchase order and processed according to policy.] 

Professional Services Check Sheet  

  YES  NO 

1. The professional services agreement is between an academic/research department/unit and a visiting scholar and/or service provider. 

   

2. The visiting scholar and/or service provider is speaking at a campus event where the department is providing direct, on‐site supervision by an employee acting within the course and scope of employment; or is providing a scholarly service such as editing manuscripts, data analysis, language editing for academic and research use under the direct supervision of an employee acting within the course and scope of his employment. 

   

3. The scholarly service provided does not include a demonstration, physical activity, or other element that presents a safety hazard to the service provider or the campus. 

   

4. The services being procured are under $5,000.     

5. A standard indemnification clause is included in the contract (see the above statement for standard language). 

   

6. All other standard University requirements for executing a professional services agreement are met. 

   

If you answered yes to all of the above items, the services being procured qualify for the expedited professional services process. Keep the completed “Expedited Professional Services form”, “Professional Services Checksheet” and “Conflict of Interest” forms on file for 5 years from date of payment.  If you answered no to any of the above items, the services being procured do not qualify for the expedited professional services processes. Guidelines for submission of your request can be found at: http://businessservices.berkeley.edu/procurement/services 

Business Services Administration ▪ University of California, Berkeley

Draft 4/2/09

CONFLICT OF INTEREST CERTIFICATION – Part A

1. Are you currently an employee of any entity of the University of California

(including but not limited to any campus, medical center, lab or the Office of the President)? YES NO

2. Are you a former employee, within the last two years, of any campus, medical

center, and/or lab of the University of California? YES NO

3. Are you a near relative of an employee of any campus, medical center, and/or lab of the University of California? YES NO

4. If you answer “Yes” to any of the 3 questions above: you must complete Part B.

(Prepare a separate Part B for each individual identified above ) 5. If you answer “No” to all 3 questions: sign and date the certification statement below.

(Do not use Part B.) I certify that the above information is true and that I am the person whose name is signed below: ________________________________________________________________________ Print Name Sign Name Date DEFINITIONS Employee - any individual who is presently employed by the University. Employee with Teaching or Research Responsibilities – an academic appointee who is engaged in teaching and/or research activities, and certain staff employees (e.g., Staff Research Associates) who may participate in teaching or research activities. Former employee – an individual who has retired or separated from the University, was dismissed, or was otherwise formerly employed by the University Near Relative – the spouse, child, parent, brother, sister, son-in-law, daughter-in-law, father-in-law, mother-in-law, brother-in-law, or sister-in-law of a University employee, and step-relatives in the same relationship. ○ Near relative also includes the domestic partner of a University employee and a relative

of the domestic partner in one of the foregoing relationships.

Definitions from Business Bulletin 43, Part 7 Employee/Vendor Relationships

Business Services Administration ▪ University of California, Berkeley

Draft 4/2/09

CONFLICT OF INTEREST CERTIFICATION – Part B Complete this page if you answered yes to any of the three questions in Part A. Prepare a separate Part B for each individual as needed (for example, you would prepare two of Part B if you were an employee within the last two years and you also have a near relative who is currently employed by the University) 1. Please list current and/or former positions held by you or your near relative: Name UC Location Department Position Date of Separation

2. Please describe your financial interest in the transaction (or the financial interest of near-relative):

3. Please describe your financial interest (or the financial interest of your near relative) in any business entity involved in the transaction:

4. Do you (or your near relative) have any past, current, or future responsibility for, involvement in, or direct influence on any of the negotiations, transactions, planning, arrangements, or any part of the decision-making process relevant to the contract?

□ NO □ YES, please explain:

5. Do you certify that no University time, material, equipment, or facilities have been or will be used in connection with any resulting purchase order or contract? □ YES □ NO

I certify that the above information is true.

Potential Vendor: Print name Signature Date

Approved: □ YES □ NO

Director of Business Services (Materiel Manager) Date