Community Education Speaker Form

Step 1 of 2

Thank you for agreeing to speak at a Community Education Course for the St. Louis Psychoanalytic Institute. Please complete as much of this form as you can. If you have questions, please reach out to Edmund Sprunger at edmundsprunger@gmail.com or the Institute at office@stlpi.org. Those items with an * listed next to them are required.
Name*
Phone*
Current Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Email*
Enter Email Confirm Email
Social Media to Tag for Marketing (Optional)
W-9
Max. file size: 2 GB.

A completed W9 Form which can be downloaded by clicking the following link. CLICK HERE FOR W9 Form . If you are incorporated, you do not need to complete a W9. We must have a copy of your W9 in order to pay you and for you to turn this in for your taxes. If you are not able to complete this online, please print and send your completed form to the St. Louis Psychoanalytic Institute at 7700 Clayton Rd. Ste 200, St. Louis, MO 63117
Please Confirm*
- I understand that the St. Louis Psychoanalytic Institute uses a service called Melio to pay instructors for their time and talent. I understand that I will be receiving an email at the address provided above which will provide me instructions on how I would receive payment for my services. We ask that you sign up for ACH delivery of your payment via Melio to save the Institute the administrative costs of processing a hard copy check. I further understand that I will not be paid until I have accepted the terms and agreements provided via Melio and until I have submitted a completed W9. Please note, if you are incorporated it is not necessary to complete a W9.

About Your Course
Title of Course*
Please Confirm*
- I understand by checking this box I will be starting my own zoom courses if this class is virtual. I also understand that the Institute will provide me with a complete training on how to do this so I do not have to worry about doing this incorrectly.
Additional Information
Biography
Headshot
Max. file size: 2 GB.

It can be a professional headshot or a snapshot that you think looks great for marketing purposes
A copy of your resume and CV*
Drop files here or

Max. file size: 2 GB.
We need a copy of your resume and CV to supply information to our accrediting bodies to obtain CEU's for the course
Please Confirm*
- I grant permission to the St. Louis Psychoanalytic Institute (Institute) its employees and agents, to take and use visual/audio ("v/a") images of me. V/a images are any type of recording of my image or voice, regardless of the method of recording or the media in which it is recorded, including but not limited to photographs, digital images, video, audio or digital tape recordings, discs, drives or other electronic storage devices, drawings, paintings or other artistic renderings, or accompanying written or auditory descriptions. I agree that the Institute owns the v/a images and all rights related to them. The v/a images may be used in any manner or media without notifying me, such as Institute Web sites, publications, promotions, broadcasts, advertisements, posters, and presentations. I waive any right to inspect or approve the finished v/a images or any printed or electronic matter that may be used with them, or to be compensated for them. I hereby release the Institute, its employees and agents from any and all liability, claims and damages that I have or may ever have related to or in connection with the taking and use of the v/a images or printed materials used with the v/a images. I hereby certify that I am 18 years old or over, and competent to sign my own name. I also certify that I have read and completely understand the contents of the above release before affixing my signature below.
Today's Date*
MM slash DD slash YYYY
Additional Information
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Community Education Speaker Form

Step 1 of 2

About Your Course

Additional Information