Request-for-Payment
Document Sample
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 this form
• Method of Payment - ORAU/ORISE will pre-pay via check or credit card. Please
provide all necessary payment information below.
POC
Name Phone Number
Credit Card Payment
Fax Number:
Registration/Payment can be completed on-line
Website:
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: Participant Costs - Other Tuition & Fees Other:
Please send completed form to ORAU/ORISE Maryland, ATTN: Brooke Elkins
4692 Millennium Drive, Suite 101, Belcamp, Maryland 21017
(410) 306-9208 ♦ Email: ORAUMaryland@orau.org ♦ FAX: (410) 306-9306
Revised 2/1/09
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: Brooke Elkins
4692 Millennium Drive, Suite 101, Belcamp, Maryland 21017
(410) 306-9208 ♦ Email: ORAUMaryland@orau.org ♦ FAX: (410) 306-9306
Revised 2/1/09
Obtaining authorizing signatures prior to
submission with assist in expediting your
reimbursement.
