Expense Reimbursement Request 1 Step 1 Contact & Payment Info 2 Step 1 Daily Expenses 3 Step 1 Upload Documents 4 Step 1 Signature & Submit 0% Expense Form Must be submitted within 30 days of completion of travel to receive reimbursement. Contact Information First Name * Last Name * Phone * Email * Meeting Attended * Location * Dates Attended * Payment Get paid by electronic transfer or check ACH Check ACH Electronic Transfer InformationPlease provide your routing and account numbers required for ACH payments. Routing Number * Account Number * Check InformationPlease provide your contact information. Address * City * State * Zip Code * Previous Next Daily Expenses Travel and related expenses are submitted in accordance with national organizational travel and reimbursement guidelines and the ENA Travel & Expense Policy. Airfare is booked at the lowest reasonable fare, with economy cabin required for flights under six (6) hours. Meal expenses are limited to a maximum daily food allowance of $100 and are claimed only for meals when food is not provided by ENA. Reimbursement is limited to travel-related expenses only; personal items are not eligible for reimbursement. Itemized receipts are submitted for all individual expenses, in compliance with documentation requirements. Maximum of 5 attachments, so receipts need to be combined into documents that can be sent together. All receipts must be attached to the reimbursement request document. Day 1 - Expenses Day 1: Date * Day 1: Breakfast Day 1: Lunch Day 1: Dinner Day 1: Course Fees Day 1: Supplies Day 1: Lodging Day 1: Airline Baggage Day 1: Airline Fare Ground Transportation (list below). Day 1: Ground Transportation 1 Day 1: GT Expense 1 Day 1: Ground Transportation 2 Day 1: GT Expense 2 Day 1: Ground Transportation 3 Day 1: GT Expense 3 Day 1: Ground Transportation 4 Day 1: GT Expense 4 Day 1: Ground Transportation 5 Day 1: GT Expense 5 Must include a copy of Google maps with mileage to treasurer. Mileage @ $0.70 (or current IRS rate) Day 1: Mileage (miles) Day 1: Mileage Amount Honorarium/Instructor Fee (Can not exceed agreed amount. Requires W9): Day 1: Honorarium/Instructor Fee Other (describe expense type in spaces below) Day 1: Misc Expense 1 Day 1: Expense Amount 1 Day 1: Misc Expense 2 Day 1: Expense Amount 2 Day 1: Misc Expense 3 Day 1: Expense Amount 3 Day 1: Total Additional Expenses Add Additional Expenses Enter expenses for 1 more day Enter expenses for 2 more days Enter expenses for 3 more days Enter expenses for 4 more days Skip - No more expenses Day 2 - Expenses Day 2: Date * Day 2: Breakfast Day 2: Lunch Day 2: Dinner Day 2: Course Fees Day 2: Supplies Day 2: Lodging Day 2: Airline Baggage Day 2: Airline Fare Ground Transportation (list below). Day 2: Ground Transportation 1 Day 2: GT Expense 1 Day 2: Ground Transportation 2 Day 2: GT Expense 2 Day 2: Ground Transportation 3 Day 2: GT Expense 3 Day 2: Ground Transportation 4 Day 2: GT Expense 4 Day 2: Ground Transportation 5 Day 2: GT Expense 5 Must include a copy of Google maps with mileage to treasurer. Mileage @ $0.70 (or current IRS rate) Day 2: Mileage (miles) Day 2: Mileage Amount Honorarium/Instructor Fee (Can not exceed agreed amount. Requires W9): Day 2: Honorarium/Instructor Fee Other (describe expense type in spaces below) Day 2: Misc Expense 1 Day 2: Expense Amount 1 Day 2: Misc Expense 2 Day 2: Expense Amount 2 Day 2: Misc Expense 3 Day 2: Expense Amount 3 Day 2: Total Day 3 - Expenses Day 3: Date * Day 3: Breakfast Day 3: Lunch Day 3: Dinner Day 3: Course Fees Day 3: Supplies Day 3: Lodging Day 3: Airline Baggage Day 3: Airline Fare Ground Transportation (list below). Day 3: Ground Transportation 1 Day 3: GT Expense 1 Day 3: Ground Transportation 2 Day 3: GT Expense 2 Day 3: Ground Transportation 3 Day 3: GT Expense 3 Day 3: Ground Transportation 4 Day 3: GT Expense 4 Day 3: Ground Transportation 5 Day 3: GT Expense 5 Must include a copy of Google maps with mileage to treasurer. Mileage @ $0.70 (or current IRS rate) Day 3: Mileage (miles) Day 3: Mileage Amount Honorarium/Instructor Fee (Can not exceed agreed amount. Requires W9): Day 3: Honorarium/Instructor Fee Other (describe expense type in spaces below) Day 3: Misc Expense 1 Day 3: Expense Amount 1 Day 3: Misc Expense 2 Day 3: Expense Amount 2 Day 3: Misc Expense 3 Day 3: Expense Amount 3 Day 3: Total Day 4 - Expenses Day 4: Date * Day 4: Breakfast Day 4: Lunch Day 4: Dinner Day 4: Course Fees Day 4: Supplies Day 4: Lodging Day 4: Airline Baggage Day 4: Airline Fare Ground Transportation (list below). Day 4: Ground Transportation 1 Day 4: GT Expense 1 Day 4: Ground Transportation 2 Day 4: GT Expense 2 Day 4: Ground Transportation 3 Day 4: GT Expense 3 Day 4: Ground Transportation 4 Day 4: GT Expense 4 Day 4: Ground Transportation 5 Day 4: GT Expense 5 Must include a copy of Google maps with mileage to treasurer. Mileage @ $0.70 (or current IRS rate) Day 4: Mileage (miles) Day 4: Mileage Amount Honorarium/Instructor Fee (Can not exceed agreed amount. Requires W9): Day 4: Honorarium/Instructor Fee Other (describe expense type in spaces below) Day 4: Misc Expense 1 Day 4: Expense Amount 1 Day 4: Misc Expense 2 Day 4: Expense Amount 2 Day 4: Misc Expense 3 Day 4: Expense Amount 3 Day 4: Total Day 5 - Expenses Day 5: Date * Day 5: Breakfast Day 5: Lunch Day 5: Dinner Day 5: Course Fees Day 5: Supplies Day 5: Lodging Day 5: Airline Baggage Day 5: Airline Fare Ground Transportation (list below). Day 5: Ground Transportation 1 Day 5: GT Expense 1 Day 5: Ground Transportation 2 Day 5: GT Expense 2 Day 5: Ground Transportation 3 Day 5: GT Expense 3 Day 5: Ground Transportation 4 Day 5: GT Expense 4 Day 5: Ground Transportation 5 Day 5: GT Expense 5 Must include a copy of Google maps with mileage to treasurer. Mileage @ $0.70 (or current IRS rate) Day 5: Mileage (miles) Day 5: Mileage Amount Honorarium/Instructor Fee (Can not exceed agreed amount. Requires W9): Day 5: Honorarium/Instructor Fee Other (describe expense type in spaces below) Day 5: Misc Expense 1 Day 5: Expense Amount 1 Day 5: Misc Expense 2 Day 5: Expense Amount 2 Day 5: Misc Expense 3 Day 5: Expense Amount 3 Day 5: Total Total Due Previous Next Upload Documents Attach maps, receipts, tickets or other supporting documentation. Max total files size 4MB File Upload Attach File No Choosen File (Max 2 MB) File Upload Attach File No Choosen File (Max 2 MB) File Upload Attach File No Choosen File (Max 2 MB) File Upload Attach File No Choosen File (Max 2 MB) File Upload Attach File No Choosen File (Max 2 MB) Previous Next Signature By signing my name below, I certify, that all the above values are accurate and in compliance with the ENA State Council/Regions Travel & Expense reimbursement policy. 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