Ver.3‐August2015
Event/Contract Request Form
Faculty Name: ___________________________________________________ Date: _____________________
Name (Speaker/Artist): ______________________________________________________________________
Last First M.I.
Address: __________________________________________________________________________________
Phone Number: __________________________________ Email: ____________________________________
Title of Talk/Service Provided: ________________________________________________________________
Date of Event: __________________________ Time: ___________ Location: __________________________________
Honorarium: _________________ Travel Reimbursement: Yes No Cost: ________________________
Not to Exceed
Expenses Covered: Lodging Transportation Meals Other: _______________________________
Funder(s) (i.e. program, club, other) Please Specify:
______________________________________________ _______________________________________________
Reception: Yes No Location:____________________ Number of people expected________________
Type of menu being requested (Contact Madeline for more information)________________________________
Attendee(s) (Name/Title):
______________________________________________ _______________________________________________
______________________________________________ _______________________________________________
______________________________________________ _______________________________________________
Contract #: ___________________________ FOPAL: _____________________________________________
ARE #: ______________________________ Amount Paid: $_______________________________________
REQUESTER INFORMATION
CONTRACTOR INFORMATION
FINANCIAL INFORMATION
RECEPTION INFORMATION
---------- STAFF USE ONLY ----------
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