Please check type of activity:
Workshop
on |
Classroom presentation |
Community presentation |
Teachers MUST complete
and sign this form. Payments are made after completion of each activity. Please
fill out form, attach additional receipts and return by mail: UCIS 223 East Franklin St., CB#5145
Chapel Hill, NC 27599-5145 or by fax: 919-962-5375
Teachers Name: |
SSN: (Required for |
Mailing Address: |
Email: |
City, State, Zip: |
Home Phone: |
Country: |
Work Phone: |
Please check:
U.S. Citizen: If Checked NO, indicate type of Visa and see* (Please provide copy of VISA, I-94, or I-AP-66) |
Yes |
No |
*Nonresident alien: Determine type of VISA and have forms 8233, PR-100
and W-8 completed prior to making a commitment for an honorarium. For
example, B-1 VISA holders cannot receive a payment, but a portion of travel
expenses can be reimbursed. Original receipts required. |
Is the above named teacher: |
|
|
|
UNC-CH employee |
Yes |
No |
|
State of |
Yes |
No |
|
Prospective UNC-CH employee |
Yes |
No |
|
Federal Employee |
Yes |
No |
|
Former UNC-CH Employee |
Yes |
No |
|
Retired from UNC of Other State Agency and receiving
retirement benefits |
Yes |
No |
NCTAN Outreach Activity:
Describe in Detail… |
Payment Type Stipend $200 Materials $…… Attach original receipts |
|
Date Completed: |
I
understand that I am required to provide on this form my social security
number so that UNC-Chapel Hill can satisfy its tax obligations under |
|