Please complete this form if you are requesting individual participant reimbursement only.

Texas Regional Collaboratives

WeTeach_CSSummit

June 7-9, 2016

UT-Austin Pickle Research Campus • Austin, Texas

Payments will arrive no sooner than three weeks after submission of ALL NECESSARY materials.

Incomplete requests will be returned, which will further delay your reimbursement check,

so please submit ALL necessary materials as soon as possible.

Participant Full Legal Name
Street Address
City
State
County
Zip Code
Phone
E-mail

Please check all applicable boxes below:

I certify that I drove my personal vehicle to the workshop site and back for this event hosted by the Texas Regional Collaboratives for Excellence in Science and Mathematics Teaching (TRC). I also understand that the TRC will reimburse me based on the state & UT mileage guidelines (odometer reading PLUS Mapquest* printout with point A to B to A addresses included with this form)at a current amount of 54¢/mile (effective 01/01/16).

I certify I drove a COMPANY/ESC/DISTRICT vehicle to the workshop site and back for this event. I have attached thorough documentation explaining policies and formulas for how figures were obtained and understand that the TRC can only reimburse institutions based on the state & UT mileage guidelines (odometer reading PLUS Mapquest* printout with point A to B to A addresses included with this form)at an amount not to exceed personal vehicle mileage rate of 54¢/mile.

I have attached my airline ticket to this form for travel to and from host city.

I have attached shuttle bus, and/or taxi receipt(s) to this form for travel to and from the host cityor local airport.

I have attached a rental vehicle receipt to this form showing full amount paid and balance due of ZERO.

If I have attached rental vehicle receipt(s), I have also attached fuel receipt(s).

I have attached parking receipts for business-related parking fees incurred while participating in this event.

I have attached my lodging receipt showing full amount paid and balance due of ZERO. I understand I can be reimbursed for no more than current state rate(depending on location) plus applicable occupancy taxes (state taxes cannot be reimbursed). See allowable rates at

Participant’s SignatureDate

Following completion of this form, please submit with all applicable receiptsto the address below

byJuly 1, 2016.**NON NEGOTIABLE**

SECURE ELECTRONIC SUBMISSION

ONLYTO

(All Individual payees(non-institutional) must also completely fill out the following page & provide a clear photocopy of your picture ID.)

* You must use MAPQUEST for all vehicle mileage calculations

If you have any questions, please email