WOI Speaker Payment Request Form 5785

Name(Required)

First Last

Email(Required)

Phone

Total agreed honorarium amount due (in Pound Sterling £)*(Required)

Total expenses incurred due in, if applicable (Pound Sterling £)

Please upload expenses here, if applicable

Drop files here or

Max. file size: 8 MB.

Please note that expenses will not be reimbursed without evidence of spend.

Account Holder’s Name: *(Required)

Bank Name: *(Required)

Bank Address:

IBAN(Required)

BIC/Swift Code*(Required)

Account Number (if applicable)

Bank Routing number (if applicable)

Currency of Account*(Required)

Special Instructions or Notes

Certification and authorisation:(Required)

I hereby certify that the above information is true and accurate

Date of submission(Required)