SMSNA RIG Expense Reimbursement Request
SMSNA will financially support RIG activities and events, up to a certain amount per RIG per year (depending on size, requirements, etc.). Prior approval of the activity/event with expenses overview is required to receive reimbursement of expenses. Eligible expenses are Audio Visual equipment/support, Food & Beverages and/or Room Rental. Receipts are required for reimbursement.
RIG Name
*
Please Select
Albany, NY
Bethesda, MD
Birmingham, AL
Burlington, VT
Central Virginia-Charlottesville/Richmond
Chicago, IL
Cleveland, OH
Cleveland Clinic, OH
Columbus, OH
Dallas, TX
Detroit, MI
Gainesville, FL
Houston, TX
Indiana
Irvine, CA
Los Angeles, CA
Monterrey, Nuevo Leon-Mexico
Montreal, QC
Nashville, TN
New England
New Haven, CT
New York, NY
Newark, NJ
Northern California
Philadelphia, PA
Phoenix, AZ
Portland, OR
Rochester, MN
Winnipeg, MB
Submitter Name:
*
First Name
Last Name
Credentials
Designation:
*
(MD, DO, PhD, etc.)
Email:
*
example@example.com
Date of Event
*
-
Month
-
Day
Year
Date
Activity/event overview and description of expenses:
*
Please fill out, sign, and upload a completed W-9 so payment can be issued. Form should be filled out with the demographics of the individual of whom is to be reimbursed.
Please upload itemized receipt(s)
*
Browse Files
Cancel
of
Total amount requested in reimbursement
*
Please be sure receipt(s) added together reflect the exact amount here
Name & address to remit payment:
*
First Name
Last Name
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
PLEASE REVIEW:
RIG Reimbursement Policy
*
By proceeding with the reimbursement request, I affirm that all information provided is accurate and that I will comply with the SMSNA RIG Reimbursement Policy.
Submitter signature
*
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