Publication Fund Request Form

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Complete this form to request support from the HTRS Publishing Fund.

1) Request Date *

YYYY

2) Applicant's Name and Credentials *

3) Applicant's Email Address *

4) Meeting Attendance *

Access to the HTRS Publishing Fund is currently restricted to awardees who attended one of the following 2021 events. Mark the event you attended below:

2021 Research Colloquium

2021 Scientific Symposium

5) What is the name of the article you are trying to publish? *

6) What journal or other professional publication are you targeting? *

7) Expected Date of Publication *

8) HTRS must be listed as a funding supporter on article: *

Example of suggested listing: "The Hemostasis and Thrombosis Research Society, Inc. provided support from its Publication Fund for Early-stage Investigators to offset the cost of publication."

Yes, agree to list HTRS according

No, unable to list HTRS (please explain further in comment section below)

Comment:

9) Are you asking for individual reimbursement (i.e. you are paying the publisher up front and being reimbursed up to $2500 by HTRS) or are you asking HTRS to pay the publisher directly? *

Individual (if you selected this option, answer questions 11 - 13) OR Pay Publisher directly (if you selected this option, answer questions 14 - 15). The limit of funds available for either option is up to $2,500 and cannot exceed this amount.

Individual Reimbursement

Pay the Publisher

10) State the amount you are requesting from HTRS ($2500 is the maximum request): *

11) Receipt of payment required for reimbursement:

Please email a copy of your receipt of payment for reimbursement to meetings@htrs.org and htrs@versiti.org for processing

Yes, my receipt has been sent

No, awaiting receipt from publisher

Clear selection

12) Payment Preference

Please email a copy of your invoice to meetings@htrs.org and htrs@versiti.org for processing

Electronic Payment - an invitation will be sent to add your email address from Bill.com (HTRS accounts payable software)

Standard Check - a check will be mailed to your preferred address

Clear selection

13) Mailing Address

14) Publisher invoice and W-9 required for payment:

Please email a copy of receipt for payment to meetings@htrs.org and htrs@versiti.org for processing. HTRS will also need a copy of the publisher's W-9 for payment.

Yes, publisher invoice and W-9 have been sent

No, awaiting invoice and W-9 from publisher

Clear selection

15) Publisher mailing address and contact information:

Provide a mailing address and contact information (phone number and email) for payment to the publisher.

16) Additional Comments

Submit

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