Symposia Speaker Travel Stipend Form - ASCB

San Diego Convention Center
#cellbio2024

Cell Bio 2024 Symposium Speaker Travel Stipend Request Form

The ASCB will provide a travel stipend to you in the amount stated in the email. In order to receive this travel stipend you must do three things: 1. Fill out the form below. 2. Set up your account in Bill.com (ASCB’s accounting system that you will receive an email from to complete account set up). 3. Attend the meeting and stay in a hotel within our housing block (unless you are local) to receive the bonus amount. Please indicate below if you are planning to accept the travel stipend or not. If we do not receive this form by December 2, and you do not fill out the bill.com information, we will be unable to provide the travel stipend.
General/Contact Information
Name (First/Given and Last/Family)*

Please be sure to list your first name and then your last name.
Please select the title of your Symposium Session*
I am would like to collect the travel stipend.
- YES
- NO
By selecting “YES”, I certify that the travel stipend that I am collecting is for eligible travel expenses (meals, airfare, train fare, ground transportation) and that the travel stipend is not being used for expenses that are being paid for or reimbursed by another entity.
Check Payable To (if different than name above; i.e. Institute)
Mailing Address for Check*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone*
Email Address of Person Being Reimbursed*
Email Address of Administrative Assistant (if applicable)
Date of Travel to San Diego, CA*
MM slash DD slash YYYY
Date of Travel from San Diego, CA*
MM slash DD slash YYYY
Upload Your W-9 Form (U.S.-Based Only)
Max. file size: 2 MB.
Please download the W-9 form here, fill it out, and upload it.
Electronic Signature and Agreement to Privacy Policy
I certify that the travel stipend is being used to pay for expenses that were incurred by me, and that are not being reimbursed by another entity.*
- By checking this box, I certify that the travel stipend is being used to pay for expenses that were incurred by me, and that are not being reimbursed by another entity.
Privacy Policy*
- By checking this box, I have read, understand, and agree to the ASCB’s Privacy Policy.
Click here to view the ASCB Privacy Policy.
Electronic Signature

In accordance with federal law, the party executing this Agreement electronically – binding the party to the same degree as a handwritten signature – by using the following process to create an electronic symbol signifying intent to be legally bound. The signor must fill in the name, institute, and date below, and check the checkbox at the end of the line marked “Electronic Signature.”
The signor shall retain a paper copy of the electronic mail.
Approved and Authorized by:
Print Full Name for Signature*
Signed Date*
MM slash DD slash YYYY
*
- Electronic Signature (Check the Box)

San Diego Convention Center #cellbio2024

Cell Bio 2024 Symposium Speaker Travel Stipend Request Form

General/Contact Information

Electronic Signature and Agreement to Privacy Policy

Electronic Signature

San Diego Convention Center
#cellbio2024