Name (please print):________________________________________________________________
Email address:________________________________________________________________
Address to which check should be mailed:____________________________________________________
_____________________________________________________________________________________________
To process your reimbursement you MUST do the following:
- Attach ORIGINAL receipts
- Sign this form at bottom
- Return reimbursement form and receipts to:
DIMACS, CoRE Bldg., Rm. 430
Rutgers, The State University of New Jersey
96 Frelinghuysen Road
Piscataway, NJ 08854-8018
Attn: DREI Program Coordinator
Questions? drei@dimacs.rutgers.edu (732) 445-4631
(Note: reimbursements take approximately four weeks to process.)
Airfare (U.S. airline only):______________________________________________
Mileage (@25 cents per mile):________________________
(please list start point:______________________________________________
and destination.):______________________________________________
Other costs (describe item and enter amount on same line):
Item#1:______________________________________________________________________
Item#2:______________________________________________________________________
Item#3:______________________________________________________________________
Item#4:______________________________________________________________________
Item#5:______________________________________________________________________
Item#6:______________________________________________________________________
Item#7:______________________________________________________________________
Item#8:______________________________________________________________________
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.
DREI'98 Education Program
DREI'98 Research Program
DIMACS Home Page