TLPCA

Reimbursement Request

Please provide the information below to request reimbursement. If you have questions, please email executivedirector@tlpca.net.

"*" indicates required fields

Name:*

First Last

What is the type of mailing address to where the reimbursement check is being sent?*

Personal

Business

University/College

Address (where reimbursement will be mailed):*

Street Address Address Line 2 City State ZIP Code

Full Address (where reimbusement will be mailed):*

Attn: Full Name of Recipient
Name of Department/Program
Name of College/Building
Full Address of University/College

Phone*

Email*

Enter Email Confirm Email

Event description and/or title:*

Date of event:*

Your role in the event:*

(e.g., regional representative, presenter, etc.)

Is the amount being reimbursed a set dollar amount or a percent (for instance, a percent of registration fees)?*

Dollar Amount

Percent

Total amount to be reimbursed:*

Percent and description (as needed):*

Reimbursement type & amount:*

Click on the + icon on the right to add multiple reimbursement types. Examples include: food, mileage, lodging, honorarium, general expenses, facility fee, other.

To calculate mileage, please use the US Government travel site. Be sure to provide the exact mileage for which you are requesting reimbursement.

Type

Amount ($ or %)

Upload receipts (if applicable/available):

Drop files here or

Max. file size: 30 MB.

Name

This field is for validation purposes and should be left unchanged.

TLPCA

Reimbursement Request

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