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Request-for-Payment

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					                                                                                                             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
                                                                                                   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

				
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