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KPAN FORMS
KPAN
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Honorarium Form
to be completed by the Peer Advisor
Kentucky Peer Advisory Network
Grant Program

PLEASE NOTE: While filling out the form below, DO NOT press the Enter/Return key as this will submit the form prematurely.

Fields designated with ** are required.

Name of Peer Advisor:  **
Mailing Address:
City:     Zip+4:
Stipend Amount: (Please select one)
        $200 / 3 hours         $400 / 6 hours
Date(s) of Service: Begin Date  **   End Date  **
Client Served:  **
Service Location:  City: 

By entering my name and email address below, I certify that I have provided   hours of on-site contact advising services to the client named above.

I understand that I am responsible for invoicing the client for expenses directly related to the consultancy, including mileage, lodging, subsistence and miscellaneous items (copying, etc.).

I understand that my advisor’s fee will be paid by the KAC upon completion of the consultancy and submission of all paperwork including this form and THE PEER ADVISOR FINAL REPORT. I also understand that I will not be paid until the client has submitted a CLIENT EVALUATION OF THE CONSULTANCY.

Name:    

Email:    

Date:     

Thank you for your interest in the work of the
Kentucky Arts Council and support of the arts in Kentucky.

    

NOTE: You must press the Submit Button to send this form.


Kentucky Arts Council
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Kentucky Arts Council
500 Mero Street
21st Floor, Capital Plaza Tower
Frankfort, KY 40601
502-564-3757
Toll Free: 888-833-2787
FAX: 502-564-2839

Page Updated: 10/02/2007

KPAN FORMS