Freedom From SmokingŪ
Stipend Request
$150
INSTRUCTIONS:
Please complete entire form and sign. If you have not previously provided us
with a W-9 Form, you will need to provide one with your first stipend request.
If your clinic had 16 or more participants, and you had a co-facilitator, then
two facilitators may apply for a stipend. Each facilitator will complete a
stipend request and provide a W-9 Form. If you do not have a W-9 form, please
go to: http://www.irs.gov/pub/irs-pdf/fw9.pdf.
Important: Stipends cannot be issued until we have a completed
Registration Form & Questionnaire and the End of Clinic Questionnaire for
each clinic participant.
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Clinic Orientation Session Date |
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Clinic Location |
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Facilitator
Name |
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Facilitator or Employer Information:
If you conduct clinics as part of your job and your employer should receive the stipend, please use your employer information
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Facilitator Name OR |
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Street Address |
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City |
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State, Zip |
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Social
Security Number |
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Signature |
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Please
print, complete and mail your stipend request, W-9 Form, Clinic Registration
& Questionnaire and End of Clinic questionnaires to:
Kelli Caseman
American Lung Association of
WV