Download:
pdf |
pdf!&
BRSS TACS | OY3 Task 9
Center&for&Social&Innovation&
HONORARIUM&FORM&
Bringing Recovery Supports to Scale
Technical Assistance Center Strategy (BRSS TACS)
!
Thank!you!for!your!participation!on!the!BRSS!TACS,!Core!Competency!Survey.!Please!complete!this!form!
along!with!a!W"9!and!return!it!no&later&than&a&month&after&you&have&received&it.&
&
This!Form!can!be!scanned!and!emailed!along&with&a&completed&W"9&form!to!
[email protected]!,!faxed!to!(781)!449K0251,!or!mailed&to:!
!
Center!for!Social!Innovation!!
c/o!Accounts!Payable!
200!Reservoir!Street,!Suite!202!
Needham,!MA!!02494!
!
Please&check&as&appropriate:&
!No,!I!do!not!accept!honoraria!for!my!involvement!on!the!BRSS!TACS!Core!Competency!Survey.!
!Yes,!I!am!accepting!honoraria!of!$25&for!my!participation!on!the!BRSS!TACS!Core!Competency!
Survey.!
!
Please&fill&out&completely:&&
Name:!
!
!
Make!reimbursement!check!payable!to! individual!or! organization:!
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Mailing!Address!(all!checks!will!be!sent!to!the!address!provided):!!
Street:
!City/State:
Phone!Number:!
Email:!
!
&&
Zip!Code:
!
!!!!
Please&Print,&Sign,&and&Date:&
!
Signature:!!!!!
!
Name:!
!!
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!
!
!
!
Date:!
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Please!contact!Accounts!Payable!if!you!have!any!questions!regarding!honoraria!via!
[email protected]!or!617K467K6014.!
&&&
| File Type | application/pdf |
| File Title | Microsoft Word - Honorarium FormCCS.docx |
| File Modified | 2014-12-12 |
| File Created | 2014-12-12 |