University of Maryland School of Medicine Office of Faculty Affairs and Professional Development GUEST FACULTY CME HONORARIUM FORM ACTIVITY INFORMATION Title of Activity: Location:
__
Date(s):
Presentation Topic/Title:
___ ___________________
FACULTY INFORMATION (please type/print) Name:
____
Degree(s): _____
_________
Home Address: City/State/Zip: Phone:
___________________ Fax:
E-mail: ______________
___
Honorarium Payable to: Amount of honorarium requested:
$
Social Security/Tax ID or Foreign Visa Number: NOT E: W e MUST receive your Social Security number in order to process honoraria. W e cannot guarantee receipt of your honorarium on the day of your lecture.
Faculty Signature
Date
Associate Dean, Office of Professional Development
Date
Controller
Date
UMGuestHonorarium Form Approved 12002
PLEASE RETURN THIS FORM IMMEDIATELY TO: Office of Faculty Affairs and Professional Development University of Maryland School of Medicine 655 W. Baltimore, St, 14015 Baltimore, Maryland 21201