NATIONAL PARK COLLEGE
HONORARIUM REQUEST
FILL IN ALL HIGHLIGHTED AREAS ON FORM
Event Date
HONORARIUM RECIPIENT INFORMATION
Honorarium Amount: $
Sponsoring
Department
Department
Contact Name
Contact's Phone Number
(enter without dashes)
Check one of the following:
Event Time Event Title
PURCHASING FORM 0006 07/28/15
PURCHASING/AP USE ONLY
Related PO #'s:
Event Location:
Honorarium: A payment given to a person for a service for which fees are not legally or traditionally required. Honorariums should be
modest in amount.
MUST CHECK ONE BOX
Address
City State Zip Code Country
Last Name First Name
Initial
SSN
Phone Number
Email
US Citizen
Resident Alien
I hereby certify that, to the best of my knowledge, the information provided is true, complete and correct.
Applicant Substitute W-9 Certification, under penalties of perjury, I certify that:
a. THE NUMBER SHOWN ON THIS FORM IS MY CORRECT TAXPAYER IDENTIFICATION NUMBER.
b. I AM NOT SUBJECT TO BACKUP WITHHOLDING.
c. I AM A U.S. CITICZEN OR RESIDENT ALIEN.
Honorarium Recipient Signature Date
MUST CHECK ONE BOX
DO NOT MAIL CHECK; RECIPIENT WILL PICK UP CHECK
MAIL CHECK TO THE FOLLOWING ADDRESS (IF DIFFERENT FROM ABOVE):
I certify that said honorarium recipient:
HUMAN RESOURCES DEPT USE ONLY
is or has been paid through the NPC payroll system during the current the calendar year
has not been paid through the NPC payroll system during the current calendar year
HR Certifying Official
Signature
Date
EMPLOYEES SHALL NOT RECEIVE PAYMENT FOR AN HONORARIUM.
(Employee payments shall be disbursed through the Human Resources Department)
It shall be the responsibility of the originating end-user department to determine the named individual is not currently nor shall be a NPC
employee during the event date(s).
Address
City
State
Zip Code
Service Honorarium to be Provided:
