Annual Retreat Faculty Remuneration Form Please complete the form below for remunerations and reimbursements. Your payment will be processed according to the specified method within 30 days of the form submission date. ODER Faculty Reimbursement Form Date(Required) MM slash DD slash YYYY Name (as shown on your income tax return). Name is required on this line; do not leave this line blank.(Required) Business name/disregarded entity name, if different from above(Required)If you do not have a business name, just write your name in this field. Mailing Address(Required)If you select check as a payment method, it will be mailed to the address you enter below. Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone(Required)Email(Required) Business EIN or SS#(Required) Check appropriate box for federal tax classification of the person whose name is entered above. Check only one of the following seven boxes.(Required) Individual/sole proprietor or single-member LLC C Corporation S Corporation Partnership Trust/estate Limited liability company Limited liability company. Enter the tax classification(Required) C=C corporation S=S corpotaration P=Partnership CE Lecture Renumeration Quantity(Required)Please enter the quantity of CE hours you provided in the quantity field. Price: $500.00 Quantity Please select preferred payment method below:(Required) Zelle PayPal Mail a check Please enter the Zelle account name & phone number below.(Required) Please enter the PayPal email account below.(Required) Do you have additional reimbursement requests? Yes No Airfare ReimbursementPlease enter the amount to be reimbursed for Airfare. You will be reimbursed up to $300 for roundtrip coach airfare and transportation to and from airport Please upload Airfare/Travel receipts.Please upload receipts for the following: Roundtrip coach airfare, Airport parking or ground transportation to and from home & event venue Max. file size: 64 MB.Mileage and Tolls ReimbursementPlease enter the amount to be reimbursed for mileage and tolls. You will be reimbursed 0.56 cents per Mileage and Tolls. Please upload Mileage and Toll receipts.Please upload receipts for the following: • Mileage and Toll receiptsMax. file size: 64 MB.Meals and Incidentals ReimbursementPlease enter the amount to be reimbursed for Meals and Incidentals. You will be reimbursed up to $75 total for meals and incidentals. Please upload Meals and Incidentals receipts.Please upload receipts for the following: • Meals and incidentals Max. file size: 64 MB.Hotel Room Accommodation ReimbursementPlease enter the amount to be reimbursed for Hotel accommodations. Optometry Divas will reimburse hotel reservations for up to 1 night – $185 plus taxes & fees Please upload Hotel Reservation receipts.Please upload receipts for the following: • Hotel Room Reservation Max. file size: 64 MB.Consent(Required) I agree to the terms of this agreementYou will receive your honorarium after your presentation and the reimbursement for your travel, meals, and incidentals within 30 days after you submit your receipts. Liability & Insurance Faculty agrees to fully defend, indemnify, and hold harmless Optometry Divas Educational Retreat (ODER), OPTOMETRY DIVAS from any and all claims, lawsuits, demands, causes of action, liability, loss, damage and/or injury, of any kind whatsoever (including without limitation all claims for monetary loss, property damage, equitable relief, personal injury and/or wrongful death), whether brought by an individual or other entity, or imposed by a court of law or by administrative action of any federal, state, or local governmental body or agency, arising out of, in any way whatsoever, any acts, omissions, negligence, or willful misconduct on the part of Faculty while a participant of the ODER, its officers, owners, personnel, employees, agents, contractors, invitees, or volunteers. This indemnification applies to and includes, without limitation, the payment of all penalties, fines, judgments, awards, decrees, attorneys’ fees, and related costs or expenses, and any reimbursements to the ODER, OPTOMETRY DIVAS, for all legal fees, expenses, and costs incurred by it.