SPEAKER REQUEST FORM

DO NOT EMAIL THIS FORM! Using the Mozilla browser (not Netscape), please complete this form to the extent possible within time limitations, print out the form, and submit the hard copy to the Colloquium Chair at least six weeks (more for foreign visitors) prior to visitor's proposed arrival date. Leave the "amount approved" and colloquium-chair signature areas blank. The form needs to be completed, approved, and signed before any visitor is invited to the UF Math Department.

If the printed-out form runs onto a second page, please staple the pages together.

Important! If your proposed visitor is not a U.S. citizen, please read the information for hosts page before filling out this form.

Today's Date Host's Name

Speaker's Name

Speaker's Affiliation and Address

Speaker's Email Address
Speaker's Fax Number (optional)

Speaker's SSN or ITIN and Date of Birth
(We are now required to obtain the date of birth in order to pay the visitor; however, completion of this item can be delayed until the visitor arrives.)

Visa Type (if speaker is not a U.S. citizen)

NOTE : Foreign visitors cannot be paid without appropriate visa status. Please do not assure your visitors of payment until the visa status is clear.

Proposed Dates of Visit

Proposed Type(s) of Talk(s):
Colloquium
Seminar . Which?
If you selected "Other" under "Seminar" , please specify:

Proposed Date(s) and Time(s) of Talk(s)

Amount Requested and Sources of Funding
Source 1 $$ Requested $$ Approved
Source 2 $$ Requested $$ Approved
Source 3 $$ Requested $$ Approved
Source 4 $$ Requested $$ Approved
Total from all sources: Amount requested

Additional Information (anything else you want Colloquium Chair to know)

I (the host) agree to reimburse the department if my visitor's keys are not returned at the end of his or her visit. (If you select "no", your visitor will be required to give a $10 deposit per key to receive key(s).)

DO NOT EMAIL THIS FORM!

Amount approved from math department sources:
Approved by: , Colloquium Chair
Date