Conference Reimbursement Request

This form is intended for recipients of the $250 travel award. You can use this to get reimbursed for airfare, baggage, car rental (and fuel), hotel, mileage, taxi/uber/lyft, etc. If unsure, just ask! Please complete this reimbursement request form by 11/15/2019. If you have any questions, please reach out to Deb Cole at lsmcecnf@iupui.edu or call 1-317-278-4753. Please allow 4-6 weeks for processing.

TRAVELER CONTACT INFORMATION

First Name

Last Name

Institution

TRAVEL DATES

Trip Start Date

Trip End Date

TRAVEL DETAILS

Transportation Mode

Select

City of Origin

State/Province/Territory of Origin

REIMBURSEMENT DETAILS

Reimbursement Payee

Select

Reimbursement Type

Please indicate for which items you request reimbursement. Check all that apply. (Note: remember, you will only be reimbursed up to $250).

Select

File Attachments

Please use this text box for any details you need to share regarding your reimbursement. No food reciepts needed.

Drag and drop files here or

WHERE TO SEND THE CHECK

If your institution paid for some or all of your travel, your institution may require that the reimbursement check should be sent to their Accounts Receivable department. Check with your mentor or department if you are unsure.

Remit To Name (who the check should be made out to?)

Address 1

Address 2

City

State/Province/Territory

Postal Zip Code

Country

NOTES

Please use this text box for any details you need to share regarding your reimbursement.

Send me a copy of my responses

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