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Request for Payment

VIEWS: 16 PAGES: 4

									                                                                                                               Received ____________________

                              ORAU/ORISE MARYLAND REQUEST FOR PAYMENT
 Please complete this form for reimbursement/pre-payment of registration fes, tuition of non-credit classes, books or other miscellaneous
                              costs that DO NOT include ORAU/ORISE reimbursement of travel expenses.
               ORIGINAL receipts and appropriate documentation are necessary in order for payment to be rendered .
  Note: Expenses that Involve Lodging and/or Per Diem Cannot be Reimbursed by Using This Form and Must be Authorized by
                                     Completing a Travel Authorization/Reservation (TAR) Form.
     PARTICIPANT NAME:
                                 First                               Middle                    Last
E-MAIL:                                                                OFFICE PHONE NUMBER:
REASON FOR PAYMENT:




   AMOUNT OF PAYMENT:                                                              PAYMENT DUE BY:
          Request ORAU/ORISE to reimburse you for an expense paid
                   •   Attach ORIGINAL Receipts or Other Proof of Payment
                   •   Reimbursement will be paid via EFT
                       I am not set up for EFT, please mail my reimbursement to the address below:




          Request ORAU/ORISE to pay an expense on your behalf
                 • Conference or Training Registration - If this is for registration to a conference or training session, you
                   MUST complete all required forms and submit with Request for Payment
                 • Method of Payment - ORAU will pre-pay via check or credit card.
                   Please provide all information necessary to render payment.
                           POC
                                                        Name                                    Phone Number
                                 Credit Card Payment (Attach completed registration form)
                                       Fax Number:
                                 Registration/Payment to be completed on-line (Provide log-in necessary to process payment)
                                           Website:
                                              Log-In ID:                                       Password:
                                 Check Payment (Attach completed registration form)
                                   Make payable to:
                                                Address:




MENTOR APPROVAL:
                                 Print Name                                        Signature


PROGRAM COORDINATOR APPROVAL:
                                                       ORAU MARYLAND OFFICE USE
ORAU/ORISE Review/Approval:                                                        /
    Project/Task #:                                                            Pay with Pcard                  Date Paid:
             Expenditure Type:           Participant Costs - Other        Other:
                                    Please send completed form to ORAU Maryland, ATTN: Travel
                                     4692 Millennium Drive, Suite 101, Belcamp, Maryland 21017
                      Phone: (410) 306-9208/9218 ♦ Email: ORAUMarylandTravel@orau.org ♦ Fax: (410) 306-9306
                                                                                                                                          Revised 11/28/11
Requests for payment of tuition & fees
for credit classes should be submitted
on the Request for Payment of Tuition




  Obtaining authorizing signatures prior to
  submission with assist in expediting your
              reimbursement.
                                                                                                   Received ____________________

                  ORAU/ORISE MARYLAND REQUEST FOR PAYMENT OF TUITION
      ORIGINAL receipts and appropriate documentation are necessary in order for payment to be rendered .
This form is ONLY for reimbursement/payment of tuition & fees for credit courses. Payment for non-credit courses
                  & textbooks should be submitted via the general Request for Payment form.
    PARTICIPANT NAME:
                                First                          Middle               Last
E-MAIL:                                                          OFFICE PHONE NUMBER:

  AMOUNT OF PAYMENT:                                        PAYMENT DUE BY:

     University:
    Term/Year:
     Course #:                                 Course Title:
     Course #:                                 Course Title:
     Course #:                                 Course Title:
     Course #:                                 Course Title:
          Request ORAU/ORISE to reimburse you for tuition paid
                  •   Attach ORIGINAL Receipts or Other Proof of Payment
                  •   Reimbursement will be paid via EFT
          Request ORAU/ORISE to pay the University directly
          NOTE: In order for ORAU/ORISE to pay the school directly we MUST receive an invoice from the institution billing
          "ORAU/ORISE". It is critical that you submit your completed request form & copy of your registration form well in
          advance of payment deadlines in order for us to send the institution necessary documents to receive the proper
          invoices for payment.
                  • Method of Payment - ORAU/ORISE will pay via check or credit card. Please
                    provide all necessary payment information below.
                          POC
                                                   Name                             Phone Number
                                Credit Card Payment
                                      Fax Number:
                                Check Payment
                                  Make payable to:
                                             Address:




MENTOR APPROVAL:
                                Print Name                              Signature


PROGRAM COORDINATOR APPROVAL:
                                               ORAU/ORISE MARYLAND OFFICE USE
ORAU/ORISE Review/Approval:                                             /
    Project/Task #:                                                     Expenditure Type: Tuition & Fees
                              Please send completed form to ORAU/ORISE Maryland, ATTN: Travel
                                    4692 Millennium Drive, Suite 101, Belcamp, Maryland 21017
                          (410) 306-9208 ♦ Email: ORAUMarylandTravel@orau.org ♦ FAX: (410) 306-9306
                                                                                                                             Revised 11/04/10
Obtaining authorizing signatures prior to
submission with assist in expediting your
            reimbursement.

								
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