Honorarium Form
Please complete this form for any individual that will receive an honorarium.
Legal Name of Recipient (if individual)
*
First Name
Middle Name
Last Name
Business Name (if honorarium will be paid to your employer). If not applicable, please record N/A)
*
Legal Address of Recipient
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Contact Phone Number
Format: (000) 000-0000.
Contact E-mail
*
example@example.com
Stakeholder group that will paying honorarium:
*
Examples: VPFA, Women in Technology, Library Accessibility Alliance, etc.
Submit
Should be Empty: