Requestor Information:Name: First Last Title: Department: Line Item Number from which compensation will be paid from:* Visiting Faculty or Guest Lecturer Information:For which campus will the contractor primarily work?*Choose OneNew MexicoFloridaBothName: First Last Title: Start Date: MM slash DD slash YYYY End Date: MM slash DD slash YYYY Proposed Compensation Rate:Choose one and enter estimated amount Physician Hourly Rate Basic Science Hourly Rate Salary $______ (for a longer-term contract) One-time payment $ _______ (for an honorarium, one-time fee, etc.) Amount: Frequency of Compensation: One Time Reoccurring Estimated hours:Choose one & enter estimate hours Hours Total Hours Per Week Hours Per Month Estimated Hours Amount: Is this Contractor for the Clinical Medicine Department?* Yes No Do we already have a faculty member at Burrell that can teach this content?* Yes No Is there space in the budget for this contractor?* Yes No Items to be attached: CV/Resume* Drop files here or Select files Accepted file types: pdf, doc, docx, gif, png, jpg, Max. file size: 8 MB. Items to be attached: Transcripts – if requesting a faculty appointment for a non-physician. Drop files here or Select files Accepted file types: pdf, doc, docx, gif, png, jpg, Max. file size: 8 MB. Enter a short description of work requested of visiting faculty/guest lecturer:*(i.e. sessions to be taught, special directions for contract, etc.)HiddenJustification for Contractor:*(i.e. Do we have someone at Burrell that can teach this session?) Request Faculty Appointment: Check if requesting faculty appointment for guest lecturer Elevated IT Access: No extra resources needed Yes – IT resources requested Please select IT Resources needed: LEO/Panapto Zoom Burrell Email Library Access Lecture Hall Drive Building Key Card Equipment (to include computer, monitors, keyboard, etc. Other Additional Information (optional):Additional Files (optional): Drop files here or Select files Accepted file types: jpg, pdf, png, doc, docx, gif, Max. file size: 8 MB. Δ