<p> WASHINGTON ASSOCIATION MEDICAL STAFF SERVICES Speaker Expense Reimbursement Report</p><p>Name Date Address City, State, Zip Telephone Purpose of trip: Travel To and From:</p><p>TRAVEL EXPENSES (Attach Receipts) Instructions: Right click each total to automatically sum.</p><p>Mon Tues Wed Thurs Fri Sat Sun Total Date Date Date Date Date Date Date Date Miles Driven** Miles Miles Miles Miles Miles Miles Miles $0.0 Mileage @ .565/mile* Taxi, Tolls & Other Other Other Other Other Other Other $0 Transportation** Hotel (Room & Tax Only – Other Other Other Other Other Other Other $0 Max per day $150) Meals (Max per day $50) Other Other Other Other Other Other Other $0 Air Travel** Other Other Other Other Other Other Other $0 TOTAL REIMBURSABLE EXPENSES $98.875 *IRS Mileage Rate as of January 1, 2013 **A total of $500.00 per meeting is available to cover airfare, transportation or driving expense, unless approved prior to purchase.</p><p>I certify that I am familiar with the provisions of the WAMSS Expense Statement and Travel Policy and this Expense Reimbursement Report is accurate as to actual and necessary business expense.</p><p>Signed: ______Date: ______</p><p>If you should have any question, please feel free to contact me.</p><p>Thank you,</p><p>Gisela Mejia, CPCS, CPMSM Joe Elder, MBA, CPCS Heidi J. Martinez, CPCS State Treasurer Western Chapter Treasurer Eastern Chapter Treasurer</p><p>Submit with receipts by mail, fax, or email to: </p><p>STATE: Gisela Mejia, CPCS, CPMSM 1915 N Wycoff Ave WAMSS Expense Report Page 1 WASHINGTON ASSOCIATION MEDICAL STAFF SERVICES Speaker Expense Reimbursement Report Bremerton, WA 98310 Phone 360-744-1848 Fax 360-744-8530 [email protected]</p><p>WESTERN CHAPTER: EASTERN CHAPTER: Joe Elder, MBA, CPCS Heidi Martinez, CPCS 747 Broadway 1806 W. Lincoln Ave Seattle, WA 98122 Yakima, WA 98902 Direct 206-386-2780 Phone: 509.574.6175 Fax 206-386-3570 Fax: 509-457-3989 [email protected] [email protected]</p><p>FOR OFFICE USE ONLY </p><p>Check # ______Date Paid : ______Account(s): ______</p><p>WAMSS Expense Report Page 2</p>