Reimbursement Request

NER Reimbursement Request

Reimbursement Request Form/Check Request Form

Please indicate below what type of request you need: ________ Reimbursement Request ________ Check Request

Date:_______________________________________________________________________________________ Name:______________________________________________________________________________________ Address: ___________________________________________________________________________________ Email address: ______________________________________________________________________________ Your Current NER Position:_____________________________________________________________________ Budgeted Line Item to be Used: ________________________________________________________________ Original Receipts Are Needed For All Reimbursements

* Note: All requests are subject to the approval of the Executive Board of the NER-AMTA prior to payment. Requests should be submitted prior to the quarterly business meeting following the transaction. Please complete all sections of the form and staple receipts/invoices to this form. Make sure that amounts listed on the receipts match amounts written on this form.