The State Center

Request for Panel Work

All fields of the form below are required. Alternately, you can fill out and email this pdf to the Executive Director.

Note: APPROVAL OF THIS WORK REQUEST BY THE STATE CENTER MAKES THE SUBMITTING ATTORNEY GENERAL’S OFFICE A PARTY (BENEFICIARY) TO THE AGREEMENT BETWEEN THE STATE CENTER AND THE CONSULTANT.

    The services described below are to be provided by (the "Consultant"), who has consented to provide such services if this Request is approved by the State Center.

    Requesting State(s) (Beneficiary(ies)):

    Description of Consulting Services:

    Anticipated Start Date of Project:

    Hours (if less than 20):

    Submitted by:

    If multiple states are making this request, please list the others currently joining in the request (only one State needs to provide the contact information requested below).

    Beneficiary (Requesting State)
    Name:
    Title:
    Office:
    Address:
    Tel. No.:
    Email:

    NOTICE: APPROVAL OF THIS WORK REQUEST BY THE STATE CENTER MAKES THE SUBMITTING ATTORNEY GENERAL'S OFFICE A PARTY (BENEFICIARY) TO THE AGREEMENT BETWEEN THE STATE CENTER AND THE CONSULTANT.