Honorarium Request

VICTORY EDUCATION & TRAINING INSTITUTE Fax (909) 592-4569

HONORARIUM REQUEST If this is the first course you teach this calendar year, a W-9 and EDD form must accompany this request.

Date:___________________________ Legal Name:_________________________________________________________________________ New Address? … No … Yes

If yes, please include a new W-9 with your request

*Are you a Licensed Minister? Yes / No Address: ___________________________________________________________________________________ City: _______________________________________State: __________ Zip Code: ____________________ Social Security Number: ___________- _____________ - ______________ Home Telephone: ___________________________ Work Number: ______________________________ Cellular: ________________________________ E-mail Address: ___________________________________

COURSE INFORMATION QUARTER:

Winter

Spring

Summer

YEAR: 20_______

Fall

(PLEASE CIRCLE)

… Intensive EXTENSION: _______________________________________________________________________________ COURSE: ___________________________________________________________________________________ Total Student Count:________________ Please allow 7-10 work days for processing. OFFICE USE ONLY ______Full Paid $__________

_______Partial Paid $__________

____Prepaid $_________

______Student Application Paid $_________

_______Sponsorship

______Audits $_______

______Enrollment Fee Paid $__________ Total $________________________

HONORARIUM REQUEST April 2009