Speaker Registration Form

PERSONAL INFORMATION

Name*

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.

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 Type

if coming from outside the United States

Last 4 Digits of Social Security Number or Taxpayer Identification Number

Dietary Restrictions

Please identify preferences, allergies, etc. that we should be mindful of when selecting meals for your visit.

SEMINAR INFORMATION

Below are questions relating to your seminar.

Lecture Date*

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 SCHEDULING

ONE-ON-ONE MEETING REQUESTS

If you have specific faculty or researchers that you'd like to meet with please list them here.

TRAVEL PREFERENCES

This 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 Information

I will need a rental car for my trip.
I will be driving my own personal vehicle for this trip.

Flight Information

Preferred Departure Airport

Preferred Airline(s)

Frequent Flyer #

Date of Departure to Madison

Date of Return from Madison

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 Notes

If you know of specific conflicts or requirements for your travel, please list them here. (Ex" I cannot depart my city until after 9 am.)

ATTACHMENTS

Please attach the following items to your form. These assist with the administration and marketing of your seminar.

Upload your Press Photo or Professional Headshot Image

Please 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 CV

Accepted file types: doc, docx, pdf, jpg, Max. file size: 24 MB.

Upload your Current W-9 Form

This form is needed to process your honorarium payment and reimbursement for any expenses you incur during your trip.

Max. file size: 24 MB.

Phone

This field is for validation purposes and should be left unchanged.