Faculty Expense Reimbursement & Honorarium Form

Faculty Expense Reimbursement Form

Please complete this form and attach all original receipts.
Faculty Name*

First NameLast Name
Email*
example@example.com
Conference Name*
Date of presentation*

MonthDayYear
Date
Do you have expenses associated with your participation in this conference that you would like the BTF to reimburse?*

No, I will cover the expenses, send me a donation receipt for the amounts (see expense details below)No, all expenses were pre-paidYes, I would like reimbursement for the following expenses (see expense details below)
Expense Details
Total amounts for reimbursement
auto-calculated, please don't write
Please upload receipts

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If an honorarium is provided (please select an option from below). Please note that we print checks once a month. All checks are mailed USPS first class.:*

I will donate my honorarium to BTF to support the Cancer Hospital in NepalSend me the honorarium via direct deposit (direct deposits are processed bi-weekly)Mail the honorarium check to me at the address on attached W9
Please upload your completed form W9 signed within the last 12 months. Form W9 is required for all honorarium payments. Honorarium checks and any year end tax documents will be mailed to the address on W9.

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Download blank form W9 here - https://www.irs.gov/pub/irs-pdf/fw9.pdf Cancelof
Due to the challenges associated with mail processing times, we are moving towards ACH payments and direct deposit for honorarium and expense reimbursement. Please let us know how you would like to receive your honorarium/expense reimbursement*

Pay the reimbursement/honorarium via check and mail the check to my address belowDirect deposit to my bank account.Other
Please upload a voided check to send your ACH payment

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Where should we mail the honoraria/reimbursement/donation receipt to?*

Street Address

Street Address Line 2

CityState

Zip Code
Any additional instructions?
Please type if you have any additional instructions such as the check to be made payable to a different person than you.
Should be Empty:

Faculty Expense Reimbursement Form