SMSNA RIG Expense Reimbursement Request

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*
Submitter Name:*

First NameLast Name
Designation:*
(MD, DO, PhD, etc.)
Email:*
example@example.com
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) and completed W-9 (above)*

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PLEASE DO NOT FORGET TO SIGN AND DATE YOUR W-9 FORM BEFORE UPLOADING. FAILING TO DO SO WILL DELAY YOUR REIMBURSEMENT!
Address to remit payment (if different of that reflected on completed W-9):

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
I understand that submission of this form does not guarantee reimbursement. I also understand prior approval of the activity/event with expenses overview is required to receive reimbursement of expenses.
Submitter signature*

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