ABCDE
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View only. To use this form, make a copy and rename it to "Reimbursement Form (FirstName LastName)".
Combine this form and all receipts into a single PDF, in the order the receipts appear on the form. Send completed forms to admin@ahli.cc within 15 days from the event date.
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Association for Health Learning and Inference
Expense Reimbursement Form
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RECIPIENT INFORMATION
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Name: Event Name:
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Email: Event Date(s):
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Phone #: Event Location:
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Mailing Address: Event Role:
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Reason for Expense:
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PAYMENT INFORMATION: Please select preferred payment method
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DIRECT DEPOSIT: Default method for individuals with U.S. accounts
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CHECK: All U.S. corporations or individuals who prefer a check
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WIRE: All non-U.S. account holders.
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Currency: All payments will be made in USDBank Name:
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Account Holder's Name: Bank Address:
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Account Holder's Phone #: Bank Account Number:
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Account holder's address:Routing Number:
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Swift Code:
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IBAN Number:
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EXPENSE DETAILS. Please attach original receipts or scanned copies.
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Item No. Receipt Date (mm-dd-yyyy)Expense Description Total Claim Amount
(incl. tax and gratuities)		For AHLI Use Only
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TOTAL 0.00
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Claimant (Print Name):Date (mm/dd/yyyy):
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Approver Name, PositionDate (mm/dd/yyyy):
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Version 2.0
January 12, 2024
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