Speaker Registration Form Personal InformationName*Middle name is needed for purchasing a flight Dr.MissMr.Mrs.Ms.Prof.Rev. Prefix First Middle Last Suffix Date of Birth*needed for flight purchases MM slash DD slash YYYY Preferred Pronouns She/Her He/Him They/Their Other Other: Job Title* Institution Name* Phone*This is the number you can be reached at in case there are issues during your travel to, or stay in Madison.Email* Home Country*Information is needed for tax purposes Country of Permanent Residence*Information is needed for tax purposes Visa Typeif coming from outside the United States Last 4 Digits of Social Security Number or Taxpayer Identification Number Dietary RestrictionsPlease identify preferences, allergies, etc. that we should be mindful of when selecting meals for your visit. SEMINAR INFORMATIONBelow are questions relating to your seminar.Lecture Date* MM slash DD slash YYYY Lecture Title*Is it ok to record your seminar?The seminar recording will only be shared internally for those who cannot attend the seminar in person. The recording will not be posted on any public platform. Yes No Travel PreferencesThis information will be used to book travel accommodations (flight & hotel) on your behalf. You should not book your own travel for this visit. We try to book accommodations that best fit your requests but are limited to availability that is also compliant with UW policy.Will you be driving or flying to Madison?Please fill out the travel section that correlations with the mode fo transportation you need. I will drive I will fly Car InformationCar Information I will need a rental car for my trip. I will be driving my own personal vehicle for this trip. Flight InformationPreferred Departure Airport Preferred Airline(s) Frequent Flyer # Date of Departure to Madison MM slash DD slash YYYY Date of Return from Madison MM slash DD slash YYYY Preferred Departure Time for Arrival Flight Morning (Before Noon) Afternoon (Between Noon - 5 PM) Evening (After 5 PM) Preferred Departure Time for Returning Flight Morning (Before Noon) Afternoon (Between Noon - 5 PM) Evening (After 5 PM) ATTACHMENTSPlease attach the following items to your form. These assist with the administration and marketing of your seminar.Upload your Press Photo or Professional Headshot ImagePlease upload a professional photo of yourself. Allowed file types: jpg, gif, png, pdf. Maximum file size is 24 MB. If your file is too large, please email to allison.bauer@wisc.edu separately.Accepted file types: jpg, gif, png, pdf, jpeg, Max. file size: 24 MB.Upload your Current CVAccepted file types: doc, docx, pdf, jpg, Max. file size: 24 MB.Upload your Current W-9 FormMax. file size: 24 MB.PhoneThis field is for validation purposes and should be left unchanged. Download Blank W-9 Form