RIG Expense Reimbursement Request

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. This form will only be accepted after the event has occurred, receipts are required for reimbursement.
RIG Name
Submitter Name:

First NameLast NameCredentials
Designation:
(MD, DO, PhD, etc.)
Email:
example@example.com
Date of Event

MonthDayYear
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

Cancelof
Total amount requested in reimbursement*
Please be sure receipt(s) added together reflect the exact amount here
* Amount must be in USD. Please use this designated currency converter to determine the amount to enter in this field. Please also be sure to change the transaction date in the converter calendar, as currency rates change daily. Amounts will be verified for accuracy.
Name & address to remit payment:

First NameLast Name
Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
PLEASE REVIEW: RIG Reimbursement Policy
Submitter signature
Should be Empty: