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University of Maryland School of Medicine  Office of Faculty Affairs and Professional Development SCHOOL OF MEDICINE FACULTY CME HONORARIUM FORM ACTIVITY INFORMATION Title of Activity:_________________________________________________________________ Location:

Date(s):

Topic/Title:

____

FACULTY INFORMATION (please type/print) Name:

________

_________________ Degree(s):

Title:

____________

Department:

___________

Address:

___

______________ _____________

City/State/Zip: Phone:

__

_________ __________________________ Fax:

E-mail:

___

_____

__________________________

Amount of honorarium requested:

$

Honorarium will be processed via University payroll. Actual payment will be net applicable FICA and Medicare taxes.

Social Security:

(required)

Dept. FAS Revolving Account Number:

(required)

Faculty Signature

Date

_________________________________ Division Head Signature

_____________ Date

_________________________________ Department Chair Signature

_____________ Date

_________________________________ Associate Dean, OGCME signature

_____________ Date

SOMHonorarium Form Revised 7­2002

PLEASE RETURN THIS ORIGINAL FORM IMMEDIATELY TO: Office of Faculty Affairs and Professional Development University of Maryland School of Medicine 655 W. Baltimore, St, 14­015 Baltimore, Maryland 21201


Controller

SOMHonorarium Form Revised 7­2002

Date

PLEASE RETURN THIS ORIGINAL FORM IMMEDIATELY TO: Office of Faculty Affairs and Professional Development University of Maryland School of Medicine 655 W. Baltimore, St, 14­015 Baltimore, Maryland 21201

http://medschool.umaryland.edu/uploadedFiles/Medschool/Offices_of_the_Dean/Faculty_Affairs_and_Profe  

http://medschool.umaryland.edu/uploadedFiles/Medschool/Offices_of_the_Dean/Faculty_Affairs_and_Professional_Development/docs/SOM_Faculty_CME...

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