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VICTORY EDUCATION & TRAINING INSTITUTE

Fax (909) 592-4569

HONORARIUM REQUEST
If this is the first course you teach this calendar year, a W-9 and EDD form must accompany this request.

Date:___________________________

Legal Name:_________________________________________________________________________
New Address? … No … Yes If yes, please include a new W-9 with your request

*Are you a Licensed Minister? Yes / No

Address: ___________________________________________________________________________________

City: _______________________________________State: __________ Zip Code: ____________________

Social Security Number: ___________- _____________ - ______________

Home Telephone: ___________________________ Work Number: ______________________________

Cellular: ________________________________ E-mail Address: ___________________________________

COURSE INFORMATION

QUARTER: Winter Spring Summer Fall YEAR: 20_______


(PLEASE CIRCLE)
… Intensive

EXTENSION: _______________________________________________________________________________

COURSE: ___________________________________________________________________________________

Total Student Count:________________


Please allow 7-10 work days for processing.

OFFICE USE ONLY


______Full Paid $__________ _______Partial Paid $__________ ____Prepaid $_________

______Student Application Paid $_________ _______Sponsorship ______Audits $_______

______Enrollment Fee Paid $__________


Total $________________________

HONORARIUM REQUEST
April 2009

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