INVITED PERSON TRAVEL ALLOWANCE REQUEST
EUROANAESTHESIA - Geneva, 3-5 JUNE 2017
Name (legible):
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City and Country:
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TRAVEL REIMBURSEMENT
In order to pay your travel allowance request by bank transfer, we require your full bank information and an original invoice or
proof of purchase.
Original invoice /Proof of flight /train /other expenses have been submitted for getting the respective allowance
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I will submit an original invoices or proofs of purchase after the congress to the ESA Secretariat by e-mail to
[email protected] or by post to Rue des Comédiens, 24 – 1000 Brussels before 30 JUNE 2017.
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BANK TRANSFER INFORMATION
Name:
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Address:
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Bank Name:
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IBAN:
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Swift Code/BIC (compulsory):
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*Sort Code (*if no Swift/BIC):
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Account number:
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REIMBURSEMENT
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Entitled to ESA Hotel + real costs (only Board members)
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Entitled to € 500 lump sum
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Entitled to ESA Hotel + € 400 lump sum (only Council
members)
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Entitled to € 300 lump sum
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Entitled to € 1.000 lump sum
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Entitled to € 250 lump sum (only NASC Members)
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Entitled to € 800 lump sum
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Other (please specify)
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Entitled to € 600 lump sum
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Please note that: Invitees coming from Switzerland are entitled to 200 € less than the above chosen lump sum; Invitees coming
from Geneva and surroundings are not entitled to any lump sum.
I DECLARE THAT
This is a complete and truthful record of my expenses related to Euroanaesthesia 2017 in Geneva (CH)
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I do not have any financial support from my department or industry to cover the travelling cost
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DATE –
SIGNED (claimant)_-
SIGNED (ESA)
You will be given a copy of this document, please keep this as a record that you have completed and submitted all information required to
complete your bank transfer. If there is any discrepancy with the payment, you will be asked to produce this document as a proof.
COMMENTS
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You will be given a copy of this document, please keep this as a record that you have completed and submitted all information required to
complete your bank transfer. If there is any discrepancy with the payment, you will be asked to produce this document as a proof.