Request for Reimbursement

 
Reimbursement of expenses for:
__ Speaker
__ Graduate student support:
 

Name:  _______________________________________________________________
 
Institution: _________________________________________________________
 
E-mail address: ______________________________________________________

Social Security No. (or, nonresidents please give visa number and type)
       _______________________________________________________________
 
Home address where check can be sent:
       _______________________________________________________________
       _______________________________________________________________
       _______________________________________________________________
       _______________________________________________________________
 
Please list your expenses below. Enclose all *original* receipts for expenses
over $10 for lodging, airfare, and transportation.
If necessary, enclose a signed statement explaining why receipts are
not available. Credit card receipts are acceptable only if
accompanied by an original bill.
If a personal car was used for transportation, please just tell us where
you drove from, and we will reimburse you based on your mileage.
 
       _______________________________________________________________
       _______________________________________________________________
       _______________________________________________________________
       _______________________________________________________________
       _______________________________________________________________
 
Days you attended the Seminar: __ Saturday __ Sunday
 
Please return before December 1, 2000, to

       Peter Constantin
       Department of Mathematics
       University of Chicago
       5734 S. University Ave
       Chicago, Il 60637
 

The Fall 2000  Midwest Partial Differential Equations Seminar is partially supported by the National Science
Foundation and the University of Chicago.