REQUEST FOR HONORARIUM
If you wish to receive an honorarium for participating in this panel review, please return the signed, original copy of this form to the Office of Scientific Quality Review during your panel meeting.
Panel:
Date:
Name: Signature: _______________________
Title:
Home Address:
Business Telephone:
Home Telephone:
Email:
We cannot pay an honorarium without the information requested.
Privacy Act Statement: The authority to collect personal information on this form is derived from Title 5, U.S.C. 301. The collected information will be used to process claims for reimbursement.
Public Burden Statement: According to the Paperwork Reduction Act of 1995, an Agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a valid OMB number. The valid OMB control number for this information collection is 0518-0028. The time required to complete this information collection is estimated to average 5 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information.
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United States Department of Agriculture, Agricultural Research Service, Office of Scientific Quality Review
5601 Sunnyside Avenue, Beltsville, Maryland 20705
301-504-3282
ARS-211P (xx/xx/xxxx)
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| File Title | INVOICE – REQUEST FOR PAYMENT |
| Author | Valued Gateway Client |
| File Modified | 0000-00-00 |
| File Created | 2021-01-30 |