Honorarium Request UConn Contact PersonHost Department* UConn Contact* First Last Email* PhoneGuest InformationGuest Name* Mr.Mrs.MissMs.Dr.Prof.Rev. Prefix First Middle Last Suffix Guest Email Do we have permission to contact the guest to initiate vendor setup?* Yes No Guest Country of Permanent Residence AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Is the guest currently an employee for the State of Connecticut?* Yes No Unsure Is the guest currently a UConn student, or work for UConn as a paid employee?* Yes No Unsure Does UConn expect to hire the guest as an employee to provide the same or similar services immediately following the termination of the activity for which he/she is receiving the payment? Yes No Unsure Nature of Services ProvidedCategory* Lecture / Seminar / Address Workshop / Committee Meeting / Panel Entertainer / Artistic Performance Other Topic or Title* Event Location(s)* Event Date(s) and Time(s)*mm/dd/yyyy format for dates HiddenEvent Date MM slash DD slash YYYY Event Website Supporting DocumentationPlease attach at least one of the following documents: event flyer or announcement invitation letter or email, or course syllabus. If you are unable to attach files to this form, email the supporting documents to: firstname.lastname@example.org Drop files here or Select files Max. file size: 100 MB. Honorarium Details7-Digit KFS # or Account Name Honorarium Amount*Brief Description of EventHonorarium Delivery Method Sent directly to the guest (preferred) Hand delivered on day of event Travel ArrangementsWill the Guest be Reimbursed for Travel Expenses?* Yes No Expenses Eligible for Reimbursement Airfare Rental Car Mileage Tolls Lodging Meals Train or Bus Other Other Expenses Does Guest Require Travel Arrangements? Yes No Travel Arrangements Requested Flight Rental Car Lodging Train Bus Other Other Travel Arrangements 7-Digit KFS # or Account Name for Travel Expenses Statement of Understanding* By checking this box, you confirm that the statements below are true and, therefore, the service provider is an independent contractor. The above-referenced service provider presented a lecture or address, conducted a training session as a one-time or occasional speaker, or presented a performance. The service provider is not a current employee or student at University of Connecticut. The service provider does not receive extensive instructions on how to perform his/her job. The service provider does provide or could be available to perform this job at other businesses/schools. The service provider does not receive benefits from University of Connecticut The university and the service provider agree, either in writing or orally, that the relationship is strictly that of an independent contractor. PhoneThis field is for validation purposes and should be left unchanged.