Speaker Renumeration Request Optometry Divas Speaker Renumeration Request Form Please complete the form below to request speaker renumerations. Once approved, you will receive a check within 30 days of the submission date on this 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) Address(Required) Street Address Address Line 2 City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal 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 Please enter the following below(Required)Chapter CityAmbassador Name Add RemovePlease identify the chapter and ambassador you’re working with below. Renumeration Requested(Required)Please enter the agreed upon speaker renumeration discussed with chapter ambassador below. HiddenDo 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 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. 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. 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 HiddenPlease upload receipts.(Required)Please upload receipts for the following: • Roundtrip coach airfare • Mileage and Toll receipts • Airport parking or ground transportation to and from home airport • Ground transportation to and from venue • Meals and incidentals 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 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 local event, 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 OPTOMETRY DIVAS, for all legal fees, expenses, and costs incurred by it.