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                          ORAU/ORISE MARYLAND REQUEST FOR PAYMENT
 Please complete this form for reimbursement/pre-payment of registration fes, tuition, 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:

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 from 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 5/7/08

				
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posted:7/27/2011
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