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Honorarium Form

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					                                        Honorarium Form
 Check requisitions for honoraria must include the social security number of the individual to whom it
 will be paid. If the check is to be issued to your institution, please provide the information below along
 with the institution’s Tax ID#. ATS has been grateful that, in recent years, several ATS faculty have
 elected to waive their honorarium in whole or in part as a charitable, tax-deductible contribution to the
 ATS Funds for the Future. If you wish to make such a donation, please note this on the Honorarium
 Form.



  Last Name                                     First Name                              Degree

  Make check payable to:        Individual

  Make check payable to:         Institution:
  Social Security or Institution Tax ID #

      Please waive payment of course honorarium in the following amount and recognize it
  as a charitable Contribution to the American Thoracic Society.

  (If you wish to earmark to one of four specific Fund areas please check off
  the category of your choice here)
      Research           Assembly Funds
      Clinical Training  International Respiratory Epidemiology Program                 $

                                                                        This is:    Home         Office
  Mailing Address


  City                                               State/Country                     Zip/Postal Code

  Institution/Affiliation


  Office Telephone                   Fax Number                       E-mail Address

  Social Security or Tax ID#

ALL FACULTY FORMS MUST BE RETURNED BY DUE DATE FOR FORMS
By Mail: Attn: Chapter Administrator/Chair
By Email: contactemail@thoracic.org

				
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posted:7/31/2012
language:English
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