Request For Honorarium Payment - Nipissing University
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3REQUEST FOR HONORARIUM PAYMENT
Complete this form for honorarium and/or honorarium-related travel expenses totaling less than $500.00
DATE OF HONORARIUM EVENT:
________________________________________
Sponsoring faculty/lead instructor/staff member name: ________________________________________
DESCRIPTION OF HONORARIUM EVENT OR PURPOSE
(Include breakdown of time and effort being recognized to justify amount)
____________________________________________________________________________________________
___________________________________________________________________________________________
HONORARIUM RECIPIENT:
Name: ______________________________________________________________________________________
Mailing Address: _____________________________________________________________________________
Honoree’s Institution/Organization/School Board ____________________________________________________
Contact Information: Telephone #____________________________Email________________________________
Social Insurance Number _________________________ Date of Birth ______________________________
Signature of Honorarium Recipient __________________________________________________________
PAYMENT:
Honorarium payment (payable by university to Honorarium recipient)
$10
$20
$30
$40
$50
$100
$150
$200
Other
$_______________
Gift/Gift Card (attach receipts)
$_______________
Travel (must adhere to Travel Policy of University – receipts required)
$_______________
TOTAL PAYMENT AMOUNT
$_______________
(Increments of $10 to a max $500 total in calendar year)
CHEQUE PAYABLE TO:
Name: ______________________________________________________________________________________
Mailing Address: _____________________________________________________________________________
Contact Information: Telephone #____________________________Email________________________________
OFFICE USE ONLY
APPROVAL
(Once the form is completed and signed, forward to the Finance Department for processing)
Approval of Dean/Associate Dean/Supervisor:___________________________________________________
Cost Centre/Object Code to be charged: ___________________ Date sent for payment ___________________
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