Address

214 Kent Ave. #256, Endwell, NY 13760

Phone Number

(844) 469-7362

Email Us

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Expense Reimbursement Request

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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

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

Receipts Required unless $20 or less.

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

Receipts Required unless $20 or less.

Course Fees
$
Supplies
$
Misc
$

Receipts with dates required for lodging and airline.

Lodging
$
Airline baggage
$
Airline Fare
$

Ground Transportation (list below). Receipts Required unless $20 or less.

$
$
$
$
$
$

Must include a copy of Google maps with mileage to treasurer. Mileage @ $0.56 (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.