Bernstein Fellows Reimbursement Form

Reimbursement Form

Bernstein Fellows
Name*

First NameLast Name
Email Address*
example@example.com
Address*

Street Address

Street Address Line 2

CityState

Zip Code

Will you be submitting mileage?

Mileage Reimbursement Calculation

	Date (MM/DD/YYYY)	Description/Purpose	Miles Traveled
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8
9
10
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Total Miles Traveled
Mileage Total Reimbursement ($) - Rate/mi = $0.70
Please attach a Google Maps screenshot showing total miles from starting location to end location to support the mileage reimbursement request. Google Maps
Attach Google Maps screenshot

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Will you be submitting hotel reimbursement?

Hotel Reimbursement

	Date(s) of Stay	Purpose	Total Amount ($)
1
2
3

Hotel Total Reimbursement ($)
Please attach hotel receipt for reimbursement. Receipts must contain the hotel name, date(s), indication of payment, and amount.
File Upload

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Will you be requesting per diem?

TOTAL REIMBURSEMENT DUE
Requestor's Signature

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Date

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Date
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