University of Maryland School of Medicine Office of Faculty Affairs and Professional Development SCHOOL OF MEDICINE FACULTY CME HONORARIUM FORM ACTIVITY INFORMATION Title of Activity:_________________________________________________________________ Location:
Date(s):
Topic/Title:
____
FACULTY INFORMATION (please type/print) Name:
________
_________________ Degree(s):
Title:
____________
Department:
___________
Address:
___
______________ _____________
City/State/Zip: Phone:
__
_________ __________________________ Fax:
E-mail:
___
_____
__________________________
Amount of honorarium requested:
$
Honorarium will be processed via University payroll. Actual payment will be net applicable FICA and Medicare taxes.
Social Security:
(required)
Dept. FAS Revolving Account Number:
(required)
Faculty Signature
Date
_________________________________ Division Head Signature
_____________ Date
_________________________________ Department Chair Signature
_____________ Date
_________________________________ Associate Dean, OGCME signature
_____________ Date
SOMHonorarium Form Revised 72002
PLEASE RETURN THIS ORIGINAL FORM IMMEDIATELY TO: Office of Faculty Affairs and Professional Development University of Maryland School of Medicine 655 W. Baltimore, St, 14015 Baltimore, Maryland 21201
Controller
SOMHonorarium Form Revised 72002
Date
PLEASE RETURN THIS ORIGINAL FORM IMMEDIATELY TO: Office of Faculty Affairs and Professional Development University of Maryland School of Medicine 655 W. Baltimore, St, 14015 Baltimore, Maryland 21201