DREI'99 Travel Reimbursement Form
Name (please print):__________________________________________________________
Email address:________________________________________________________________
Address to which check should be mailed:______________________________________
______________________________________________________________________________
______________________________________________________________________________
Dates of Attendance:__________________________________________________________
To process your reimbursement you MUST do the following:
1.Attach ORIGINAL receipts
2.Sign this form at bottom
3.Return reimbursement form and receipts to:
DIMACS, CoRE Bldg., Rm. 412
Rutgers, The State University of New Jersey
96 Frelinghuysen Road
Piscataway, NJ 08854-8018
Attn: Barbara Kaplan, Financial Assistant
Questions Contact:bkaplan@dimacs.rutgers.edu
(Note: reimbursements take approximately four weeks to process.)
Airfare (U.S. airline only):______________________________________________
Mileage (@25 cents per mile):_____________________________________________
Starting point:______________________________________________
Destination:_________________________________________________
Other costs (describe item and enter amount on same line):
Item#1:______________________________________________________________________
Item#2:______________________________________________________________________
Item#3:______________________________________________________________________
Item#4:______________________________________________________________________
Item#5:______________________________________________________________________
I certify that the attached receipts are appropriate and accurate.
Signature
You may use this as a template - fill in the information, print it out,
sign the form, then mail it along with your original receipts, to me.