GuLFOMBattachment21NEWAppendix_V_-_Participant_Remuneration_Receipt_Form

Appendix V: Participant Remuneration Receipt Form

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RECEIPT

Date _____________

I have received a $50.00 stipend for participation in the GuLF Study.
(Gift Card Serial # _______________________)

I have received a $10.00 stipend for providing an additional Quality Control Sample for the GuLF Study
(Gift Card Serial # _______________________)

__________________________________
Participant’s signature

Participant Name: ___________________________________
Participant ID: ___________________________________
Address: ___________________________________

__________________________________

City, State, Zip:___________________________________

Witness signature

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