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
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
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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