Obtain permission from the Executive Director before using this form. Name* Date* MM slash DD slash YYYY Position* Event* Home Address* Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone*Email* Enter Email Confirm Email MileageFrom To From To Total Miles @.54 per mile Hotel Name Hotel Charges Attach ReceiptMax. file size: 25 MB.Meals: (indicate the number of meals claimed)Breakfast ($10.00) Lunch ($15.00) Dinner ($20.00) Total Amount Meals Claimed: Miscellaneous Expenses (Attach Receipts below): Total Amount Miscellaneous Claimed: Attach ReceiptMax. file size: 25 MB.Total Expense Claim: CAPTCHA