UNIVERSITY CENTER FOR INTERNATIONAL STUDIES (UCIS)

NCTAN ALUMNI OUTREACH PAYMENT REQUEST FORM

 

NCTAN Administrator and Payment Approval:  Bogdan T. Leja

 

Please check type of activity:

 

Workshop on East Asia

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

 

                  

 

                                                                                                                                                                                                         

                                                        Your Information:

Teachers Name:

SSN:  

(Required for U.S. and nonresident alien individuals*)

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 NC employee         

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

 
Your Signature

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 North Carolina and federal laws. Unless I have struck through this sentence and put my initials beside this sentence, I voluntarily permit UNC-Chapel Hill also to use my social security number as a personal identifier for other internal record-keeping and data processing operations of UNC-Chapel Hill.