Out-of-State Clinician Info Form – Draft – MMEA

Description of Policies Here

Out-Of-State Clinician/Participant: Contract/Agreement Information (Draft)

Step 1 of 3

Clinician Information
Name*
First Last
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Cell Phone*
Email*

Enter "none@mmea.net" if no email.
Business ID / Social Security Number
Include ONLY if payment is over $500.

Terms of Agreement
*MMEA agrees to pay the following expenses (Pre-Negotiated):
Appearance Fee*
*Includes ALL scheduled appearances throughout the conference.
Transportation Needed:*
- Yes
- No
If Yes (Check ALL that apply):
- Air Transportation
- Ground Transportation
- Air + Ground Transportation
Lodging Required:*
On-Site Meals to be reimbursed:*
- Yes
- No

Sponsorship Information
Clinician Sponsor agrees to pay the following expenses:
*Check ALL that apply
Sponsor / Company Name:
Representative Name
Representative Email
Representative Phone