Travel Expense Reimbursement Request Form

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American Physical Therapy Association
1111 North Fairfax Street, Alexandria, VA 22314-1488 (703) 684-2782
TRAVEL EXPENSE REIMBURSEMENT REQUEST
NAME (PRINT) ___________________________________________________  MEMBER  NON-MEMBER  STAFF
SEND CHECK TO:
___________________________________________________________________________________________________
STREET
_____________________________________________________________________________________________________________________
CITY
STATE
ZIP
PURPOSE OF TRAVEL
CONTACT AT APTA
_______________________________
_____________________________________
TRAVEL
CITY
FROM:
TO:
TO:
TO:
DATE
TOTAL
AIRFARE or RAIL
(Documentation Required)
GROUND TRANSPORTATION
CAR MILEAGE
(Personal Auto-57.5 cents/mile)
CAR RENTAL
HOTEL-ROOM
*
BREAKFAST
*
LUNCH
*
DINNER
**
MISCELLANEOUS
STAFF EXPENSE RECORD
TOTALS
LESS TRAVEL ADVANCE
*See Reverse Side for Reimbursement Limits
LESS EXPENSES PAID BY/CHARGED TO APTA
TOTAL REIMBURSABLE
**
MISCELLANEOUS EXPENSE RECORD EXPLANATION
DATE
NAME OF GUEST (S)
ASSOCIATION PURPOSE
PLACE EXPENSE OCCURRED
AMOUNT
I CERTIFY THAT THIS
STATEMENT IS TRUE: _________________________________________________________ DATE: ______________________________
(SIGNATURE)
DATE: _____________
DATE: _____________
PROG DIR APPROVED:
VP APPROVED:
CFO APPROVED:
DATE:
FOR STAFF USE ONLY
PROGRAM OR PROJECT #
ACTIVITY #
FOR ACCOUNTING USE ONLY
CHARGE TO:
DATE PAID
CHECK NO.
APPROVED:

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