UT Math Request for Visitor Authorization

(THIS FORM IS TO BE SUBMITTED 2 WEEKS PRIOR TO VISIT)
Today's Date: 02/19/2020

Visitor's Name:  Academic Title:
SSN:   Email:
   Check if you don't have a SSN.   

Disclosure of your Social Security Number ("SSN") is required of you in order for The University of Texas at Austin to process your reimbursement, as mandated by State and Federal law. Further disclosure of your SSN is governed by the Public Information Act (Chapter 552 of the Texas Government Code) and other applicable law.

    Name of Your Host:          Email of Your Host: 

US Citizen?     Yes    No

Visa Category (non-citizen only)
This information is very important. Lack of proper work authorization may result in non-payment.
  J-1 Country passport issued by:
  H1-B
  B1/B2
   WB/WT or Visa Waiver Program
  Permanent Resident
  of the USA		    Green Card No.
  Other, please specify 
Please see Elisa (bass@math.utexas.edu) for questions about visa issues.

Employment Status
  Non-Texas State Employee   Federal Employee

Nature of Service (check one)
  Guest Lecturer   Continuting Education   Conference Participant
  Student   Other Professional Activities

Dates of Visit (MM/DD/YYYY)
Arrival Date :    Departure Date: 

Institution Name, Full Address and Department

Full Mailing Address for reimbursement (preferably home address/must include street address and zipcode)


Description of Services, Including the Title of Talk


Provided by Host


Funding Source: 
Time and Location of Talk: 

Is this guest a job candidate?      Yes   No

Note: Direct paid items are not allowed using state funded accounts
Direct Paid: Lodging:     Yes   No
 Other Direct Paid Items:     Yes   No
Specify Other Direct Paid Items:

For lodging arrangements, please contact your account manager.

Estimated Expenses
Fee:   Transportation:   Lodging:   Meals:
Other (specify)

If this request is late, please provide a short explanation to the Dean
Office Use
Lodging Conf. #:  Daily Rate: 
Name of Hotel:  Total Fee: 
Acct Title:  Transportation  
Account #: Lodging: 
Acct Title:  Meals  
Acct #: Other
Estimated Total:

Specify Notes:



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