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 - up to $2,000 per RIG). 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
Atlanta, GA
Chicago, IL
Cleveland, OH
Detroit, MI
Gainesville, FL
Houston, TX
Irvine, CA
Miami, FL
New York, NY
Phoenix, AZ
Winnipeg, MB
Submitter Name:
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First Name
Last Name
Designation:
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(MD, DO, PhD, etc.)
Email:
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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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Cancel
of
Address to remit payment (if different of that reflected on completed W-9):
Street Address
Street Address Line 2
City
State / 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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