Round Table on Information Access for People with Print Disabilities Inc	
									
CLAIM FORM REIMBURSEMENT OF EXPENSES


I [insert your name] request the assistance of the Round Table with reimbursement of expenses incurred in attending:

Description of meeting:
Where meeting was held:
Date of attendance:

Expense

Airfare
* Amount: $
* Type of reimbursement (full or allowance):
* Receipt attached (yes/no):

Accommodation
* Amount: $
* Type of reimbursement (full or allowance):
* Receipt attached (yes/no):

Out of Pocket Expenses
* Amount: $
* Type of reimbursement (full or allowance):
* Receipt attached (yes/no):

Other:
* Details:
* Amount: $
* Type of reimbursement (full or allowance):
* Receipt attached (yes/no):


TOTAL	$

Details of other expenses claimed above:

The total amount claimed of $

Please give name of account this expense should be debited against the (if appropriate): 

Bank account details for direct credit payment:


Signed:

Round Table Member:

Date:


Round Table on Information Access for People with Print Disabilities 
ABN 64 941 990 153
PO Box 229, Lindisfarne, Tasmania 7015
Telephone: 03 6265 1519
Email: admin@printdisability.org

END of form.