Emergency Medicine - Reimbursement Request

Reimbursement requests must include all items below, including attached documentation for all charges.

Short summary (e.g. name of event, major item(s) purchased, etc.)

Request Type

What type of funds will be used to support this reimbursement request?

  • Grant funding: Provide FAU if available or name of grant; list Research Administrator and email address
  • Faculty Education Fund
  • Department funding (please also attach approval)

If you are submitting several receipts and are unsure of the reimbursable total, we can calculate this for you.

Please describe the event or item(s) purchased. For conferences, include the conference name, travel dates, and requestor's activities (presenting, attending, etc.). For purchases, please note the items' relevance to department activities.


If you are requesting mileage reimbursement, please complete and attach the Mileage Reimbursement Request.

For events or purchases spanning multiple days, please enter the first date of travel or first date of purchase, whichever is earlier.

Were any flights or lodging reserved and direct billed by the UC Travel Center? If so, please note the booking confirmation number(s) here and attach the invoice with your other attachments below.

Please attach all receipts along with redacted credit-card statement(s) showing the requested charges. For ease of reconciliation and processing your reimbursement, please attach each receipt as a separate PDF file rather than combining items together.

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