OCHSNER CLINIC FOUNDATION by y486F4V

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									  SEMINAR REGISTRATION CHECK REQUEST & RELATED TRAVEL REIMBURSMENT AND APPROVAL FORM

 This form is to be used by employees requesting advance payment of registration fees for seminars and/or meetings. Please have this form
 approved and signed by your Program Director/Chairman. Submit the original signed form along with all original receipts taped to an 8 ½ x 11
 piece of paper to Graduate Medical Education for processing through Accounts Payable. Maintain a copy in the departmental files.

                                                        REGISTRATION FEE SECTION

OCF CO. CODE: 0130 COST CENTER # ________________ G/L EXPENSE # 84210                                     Activity Unit _____________

DEPARTMENT NAME AND PHONE NUMBER:__________________ __________________________________________

 Approval: I, _____________________________________________ do hereby authorize _________________Registration Fee for this conference
                  (Program Director’s Signature)                                   Total of Check)

       Academics Approval Signature: ________________________________________________________________           Date ________________________


Registration          Registration Fee Payable To:                                                          __________________
                      Complete Address:                                                                                           __________________
                      City, State & Zip:                                                                                          _________________


 Employee Attending: ____ _______________________________________________________________________

 Date(s) of Meeting: __________________________________________________________________        Check Required By:_______________________

                NOTE:          REGISTRATION FORMS TO ACCOMPANY CHECK REQUEST - ORIGINAL & ONE COPY

                                                                TRIP EXPENSE REPORT
 Employee’s Name: _________________________________________________________________________ Beeper No: ____________________________

 Employee Home Mailing Address _____________________________________________________________________________________________________

 Employee SS # ________________________________



               Day/Date                       Sun.       Mon.        Tues.           Wed.        Thurs.         Fri.             Sat.      TOTAL
                                           ____/____   ____/____   ____/____     ____/____    ____/____     ____/____      ____/____
               Meals - 84215

               Hotel - 84215
               Airfare - 84215
               Rental Car - 84215
               Mileage Amount - 84215
               Registration Fee - 84210
               Other (Describe) 84215

 If you traveled by car, please indicate total mileage traveled: ____________miles
 @.445 cents per mile = $____________(should agree to mileage amount above)                    Total Expense
           GME INFORMATION BELOW:                                                              Less Personal Expenses Included
 Cost Center                                     84215 Total                                   Net Expense
 Cost Center                                     84210 Total                                   Amount Due Employee

Travelers’ signature: ________________________________________________________________ Date:____________________________________________

Approved By: ______________ __________________________                         _______________________________________________________
                Program Director’s Signature    Date                               Janice Piazza, Vice President - Academics Date
                                               DAILY WORKSHEET FOR MEALS


                 Sunday        Monday         Tuesday      Wednesday   Thursday   Friday   Saturday
                      /              /              /           /           /         /         /

   Breakfast
      Lunch
      Dinner
       Total


NOTE: Please list only your daily totals for meals on page 2

								
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