APPENDIX IV: FORMS

Association of State and Territorial Directors of Nursing

FEE AND TRAVEL AGREEMENT FOR CONSULTANTS

I, ______________________________, agree to present at the __________________

                 (Name)

_______________________________________ Program schedule on
               (Program title)

_______________ at ___________________.  My Professional

       (Date)                                 (Location)

Fee will be in the amount of $ _________.  I understand that my travel expenses for either

mileage by car ___________ at current IRS rate or plane fare $ __________ (coach rate), food and

lodging for _____ days will be reimbursed.  Reimbursement for the travel expense will not

exceed $ ____________.

_____________________________________            ________________________

Consultant Signature                                             Date

_____________________________________            ________________________

ASTDN Representative Signature                  Date

Consultant Information:

SSN/FEIN: __________________________

Name: ______________________________

Street: ______________________________

City: _______________________________

State: ______________________________

Phone (W) _________________Phone (H) ___________________ Fax ________________