STIPEND REQUESTS

  • This form is for requesting a stipend payment.
     
  • If this is your first time making a Stipend Request, please click here for instructions.
     
  • Important! Stipend payments for study participation must be included as part of the contract agreement and align with your ICF document.

Download a copy of the W-9 form for Residents of the United States

Download a copy of the W-8BEN Form Non-U.S. Residents in the AMERICAS

Site Number*
Patient Number*
Full Study Number,
Protocol Number or BC# *
Sponsor Name*
Patient Name*
 
PLEASE COMPLETE THE INFORMATION BELOW FOR THE STIPEND REQUEST
Number of Travelers*
Stipend Amount
Visit Dates Included
Visit Type
Please ensure the visit type and date of service are correct prior to submission. Inaccurate information may result in processing delays.
Additional Comments

 

Site Coordinator REQUESTING STIPEND Prepaid Card
Sit Coordinator Name*
Site Coordinator Phone Number*
Site Coordinator Email Address*

 

Person RECEIVING STIPEND Prepaid Card
Recipient's Name
Recipient's Postal Address to receive cards*
Recipient's Phone Number
Stipend Country*
Comments

 

UPLOAD FORMS
Upload your completed forms here
 
If the request falls outside the scope of work, please provide a justification so we may seek approval from the sponsor.
Request Justification

 

 

Colpitts Clinical Phone Number: 781-471-2336 or Toll Free: 855-283-1755

 
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