New Affiliation Contract Application New Affiliation Contract Application Heading link Copy link Step 1 of 5 20% CONTRACT INFORMATIONType of Contract * RequiredSelect a category to populate the form Payable: Please click here if your unit is paying the partner. No Funds: Please click here if no funds are exchanged. Receivable: Please click here if your unit is being paid for activity/ies under this contract. Contract Description * Required New Contract Amendment [Below, please provide the Contract Number of the original document we are amending.][Below, please provide the Contract Number of the original document we are amending.] Proforma UploadProforma is required for all revenue generating agreement. Please prepare the pro-forma with your Fiscal Officer. Once the pro-forma has been signed by Dean or authorized signee, please upload. For more information about revenue generating agreements and to download your proforma, please see https://cfo.uic.edu/about-us/budgetoffice/policies/contract-based-educational-programs/ Max. file size: 15 MB.Amount * Required[If NO FUNDS, please enter "0" (zero)] Health Related College? * Required Yes No Procurement Method * RequiredBidRFPSole SourceRFISmall PurchaseRFQEmergencyBAFOExemptionGroup PurchaseBulletin Procurement # If Unit has previously contracted with vendor, previous contract number Do the activities supported by this contract involve sharing or transfer of personal data? * Required Yes No Please confirm if the planned activities include patient contact, either verbal or physical. * Required Yes No Type of CoveragePlease indicate the Occurrence Limit:General LiabilityAuto LiabilityProfessional Liability (Medical)Please indicate the Aggregate Limit:Please indicate the Aggregate Limit:General LiabilityAuto LiabilityProfessional Liability (Medical)Protected Health Information (PHI) Involved? Yes No Does the proposed activity share students' data in any form? Yes No Chart Fund Org Account Program Activity Location Length of AgreementThe standard lenght is five (5) years. If requesting a shorter length, please specify the amount of time below. Start DateInternational affiliations become effective on the day of last signature. If for any reasons you need a specific date, please provide us with the date and explain the reason.Language of AgreementThe standard language for UIC agreements is English. If another language is entered, a translation will be required and OIA will obtain a certified translation, all costs to be born by the initiating unit. If applicable, please enter the second language for this agreement: Document Source * Required Template No Changes (if you are using a UIC template) Template With Changes (if you have entered changes to the UIC template) Custom (if specially negotiated for this specific activity) Other Party (if provided by the partner school) Please drop or upload below the agreement/contract to be reviewed. Drop files here or Select files Max. file size: 15 MB. ABOUT UIC PRINCIPAL INITIATORName * Required First Last Rank / Title * Required Department/Office * Required College * Required Mailing Business Address * Required Street Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country M/C * Required Phone * RequiredFax Email Address * RequiredProvide UIC Mail ID ABOUT AREAS OF COLLABORATIONS AND ACTIVITIESPROPOSED AREA/S OF COLLABORATION * Required Professional Development Faculty Exchange Consulting/Advising Contract Based Program** Teaching/Research Other Placement Abroad, clinical and no-clinical Student Exchange/Study Abroad **“Contract-Based (CB)” are self-supporting instructional programs. These programs are considered to be revenue-generating contracts and must be substantiated by an approved proforma. Please contact your Fiscal Officer to proceed with a self-supporting program.If Other Please DescribeActivities will Benefit UIC's * Required Undergraduate Students Staff Graduate Students Faculty Other If Other Please DescribeInformation about Proposed Activities * RequiredPlease provide a description of the program you wish to establish. Please notice that the main goal of this section is to help to elaborate around the strategic merit and value of the proposal. As applicable, please provide a brief summary of the planned collaborative activities, implementation time frame, method of assessing outcome/s, and overall value of the collaboration to the sponsoring UIC unit and campus as a whole: If applicable, please attach every supplemental material that you consider necessary and describe any provision unique to the proposed program, such as internship placement, housing, field trips, excursions, specific qualifications of participants, etc.If applicable, please attach every supplemental material that you consider necessary and describe any provision unique to the proposed program, such as internship placement, housing, field trips, excursions, specific qualifications of participants, etc. Drop files here or Select files Max. file size: 15 MB. INFORMATION ABOUT COLLABORATING INSTITUTIONWhy this institution? * RequiredPlease provide background information of the collaborating institution, as well as the reasons for establishing a formal relationship. Include links as needed.Name of Institution * Required Institution Official Acronym or Initials * Required Contact Person Name * Required First Last Contact Rank/Title * Required Contact Department Office * Required Contact Address * Required Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Phone * RequiredEmail * Required Fax Website * Required Authorized Signature at Partner InstitutionInformation of Authorized Signature at partner Institution, if known. Please note that the authorized signature could be the institution's president, rector, chancellor, provost, dean or director of a specific laboratory. You want to check with your colleague at partner institution to confirm the right authorized signature.Authorized Signature Name * Required First Last Authorized Signature Rank / Title * Required Please notice that University Counsel review is required for payable contracts of $250,000 or more, all contracts requiring BOT approval, all settlements of claims or disputes, all contracts for legal services, all contracts where student data will be shared with outside entities, and all employment contracts, all revenue generating healthcare contracts, and all other party revenue generating contracts.Approval and Certification * RequiredI certify that to the best of my knowledge that the information provided on this form is correct and complete. In the event that this agreement is approved, I agree to abide by UIC’s International Collaboration Policy and all applicable institutional, collaborator, and sponsoring agency policies and procedures of the University of Illinois at Chicago and Before submitting, please type in your name * Required CommentsThis field is for validation purposes and should be left unchanged.