Special Services Agreement Request

Directions: To initiate a Special Services Agreement request, please fill this form out completely, accurately, and legibly AT LEAST one month prior to the date of service. Special Services Agreement Request forms that are submitted following the date of service will not be honored. The lack of any necessary information may cause prolonged processing.

The successful completion and submission of this form will result in:

  1. The generation of a Special Services Agreement on behalf of the Monroe Community College Association, Inc. with the Special Services Contractor that you designate
  2. The generation of a Funding Request Form

Once this form is processed, a special services agreement and a blank W-9 Request for Taxpayer Identification Number and Certification form will be sent (via the United States Postal Service) to the Special Services Contractor that you designate at the address that is listed on this form. The Special Services Contractor will have two weeks to return the signed special services agreement and the completed and signed W-9 Request for Taxpayer Identification Number and Certification form to the Monroe Community College Association, Inc. Failure to remit all necessary paperwork within the two-week time-span will result in the cancellation of the special services agreement and all of the terms therein. The Monroe Community College Association, Inc. will not be responsible for following-up with the Special Services Contractor should the reply to the special services agreement not be submitted in a timely manner. Once a special services agreement is cancelled, the submission of another Special Services Agreement Request form will be necessary to initiate a new special services agreement between the Monroe Community College Association, Inc. and the Special Services Contractor.

PAYMENTS WILL BE SENT TO THE SPECIAL SERVICES CONTRACTOR (via the United States Postal Service) AFTER THE DATE OF SERVICE PENDING SUCCESSFUL COMPLETION OF ALL TERMS OF THE SPECIAL SERVICES AGREEMENT

Host Information
Your Name:
Phone Number:
E-mail Address:

Special Services Contractor Information
Agency/Name By Which
Contractor Operates:
Social Security Number/
Employee ID Number:
Address Line ONE:
Address Line TWO:
Phone Number:
E-mail Address:

Special Services Agreement Terms
Description of the Services Date Time Venue Amount Payable
(1-hour lecture) (00/00/00) (0:00 AM) (Monroe A) ($1,000.00)
Funding:  Project Name (ID#): Creative Arts (1527)   Performing Arts (1525)
Account Name:   Account ID #:
Accommodations:  Hotel Accommodations are NOT necessary
Hotel Accommodations are necessary
         Check-in Date:  Check-out Date: 
      Number of Rooms:  Number of People: 
Please note that all hotel accommodations will be made at Best Western Rochester Marketplace Inn, 940 Jefferson Road, Rochester, NY 14623 unless otherwise noted. A non-smoking room with a king sized bed will be reserved in the Special Services Contractor's name unless otherwise specified below.

Other Specifications:
mcc-web02.monroecc.edu