Address

214 Kent Ave. #256, Endwell, NY 13760

Phone Number

(844) 469-7362

Email Us

Info Here

Install our APP

More Info

Join

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

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 @ $0.67 (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.