Georgetown University School of Medicine Student Council

`Student Reimbursement Form`

*Please use one form per event*

* Club or Organization:

Check payable to:

* First Name

* Last Name

* Street Address

Address Line 2

* City

* State

* Zip Code

Phone Number

Email Address

* Employed by Georgetown (including AV, library, MNTS, or listed in the hospital or university payroll)?

Itemized Spending:
Please enter the item description and cost

	Item description	Cost
1.
2.
3.
4.
5.

Total Amount spent:

* Date and Brief Description of Event:

* Number of students attending event:

* Number of non-students attending event (please specify):

*****
* You must submit the ORIGINAL receipt to the Executive Council Treasurer in order to be reimbursed!*
*No original receipt or credit card statement = no reimbursement*
*****
*Reimbursement takes 6 to 8 weeks*
*Checks will be sent to the address listed above, not to school mailboxes*

* Indicates Response Required