Address

214 Kent Ave. #256, Endwell, NY 13760

Phone Number

(844) 469-7362

Email Us

Info Here

Install our APP

More Info

Expense Reimbursement Request

Return to Forms

NEW YORK STATE COUNCIL
EMERGENCY NURSES ASSOCIATION
Expense Reimbursement Request

For speakers, delegates, courses/teaching days, conferences etc.


* Indicates a Required Field

Receipts must be submitted to the treasurer

Zelle Information

Please provide at least one information required for Zelle payments - Phone or Email.

Must be submitted within 30 days of completion of travel to receive reimbursement.

Maximum Daily Meal Allowance is $100.


Sunday

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

DATE

TOTAL

Travel and related expenses are submitted in accordance with national organizational travel and reimbursement guidelines and the ENA Travel & Expense Policy. Airfare is booked at the lowest reasonable fare, with economy cabin required for flights under six (6) hours. Meal expenses are limited to a maximum daily food allowance of $100 and are claimed only for meals when food is not provided by ENA. Reimbursement is limited to travel-related expenses only; personal items are not eligible for reimbursement. Itemized receipts are submitted for all individual expenses, in compliance with documentation requirements. Maximum of 5 attachments, so receipts need to be combined into documents that can be sent together. All receipts must be attached to the reimbursement request document.

Breakfast
$
Lunch
$
Dinner
$
Sub-Total
$
$
$
$
$
$
$
$

Course Fees
$
Supplies
$
Misc
$

Receipts with dates required for lodging and airline.

Lodging
$
Airline baggage
$
Airline Fare
$

Ground Transportation (list below).

$
$
$
$
$
$

Must include a copy of Google maps with mileage to treasurer. Mileage @ $0.70 (or current IRS rate)

Mileage (miles)
miles
Mileage Amount
$

Honorarium/Instructor Fee (Can not exceed agreed amount. Requires W9):

Honorarium/Instructor Fee
$

Other (describe expense type in spaces below)

$
$
$
$
Daily Totals
$
$
$
$
$
$
$
$
Less Advances:
$
Total Due:
$

Attach maps, receipts, tickets or other supporting documentation. Max total files size 4MB

By signing my name below, I certify, that all the above values are accurate and in compliance with the ENA State Council/Regions Travel & Expense reimbursement policy.