Speaker Registration Form PERSONAL INFORMATIONName*Type name as it appears on your government ID you'll use while traveling. Middle name is needed for purchasing a flight. If you do not have a middle name please put "N/A" in that slot to let us know. First Middle Last Suffix Middle Name*Middle name is needed for purchasing a flight. Yes, included above No, I do not have a middle name 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 purposesCountry of Permanent Residence*Information is needed for tax purposesVisa Typeif coming from outside the United StatesLast 4 Digits of Social Security Number or Taxpayer Identification NumberDietary 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 DAILY SCHEDULINGONE-ON-ONE MEETING REQUESTSIf you have specific faculty or researchers that you'd like to meet with please list them here. TRAVEL PREFERENCESThis information will be used to book travel accommodations (flight & hotel) on your behalf. Please, do 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 AirportPreferred 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) Flight Schedule NotesIf you know of specific conflicts or requirements for your travel, please list them here. (Ex" I cannot depart my city until after 9 am.)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 FormThis form is needed to process your honorarium payment and reimbursement for any expenses you incur during your trip.Max. file size: 24 MB.PhoneThis field is for validation purposes and should be left unchanged. Download Blank W9 Form