OHIO ANCIENT ORDER OF HIBERNIANS
2011 REIMBURSEMENT REQUEST
REQUEST DATE: _____________________
NAME: _____________________________________ (PRINT)
OFFICE: ____________________________________
ADDRESS: __________________________________
____________________________________________
PURPOSE:
E-Mail: _____________________________________
 STATE /  NATIONAL CONVENTION
 STATE BOARD MEETING
 OTHER FUNCTION:_____________________________________________________
DATE OF MEETING/FUNCTION: ______________________________
CONVENTION PACKAGE/REGISTRATION (if applicable):
$ _____. ___
( 7540/7840 )
TRAVEL:
FROM: ________________TO __________________ = ________MILES @ $0.14 times 2=
(Mileage ROUND TRIP, Rate Effective 07/19/2009)
$ _____. ___
( 7500 )
HOTEL (NAME) _________________________
$ _____. ___
( 7920 )
_____NIGHT (S) @ $ ________PER NIGHT
POSTAGE:
FOR:____________________________________________________________________________
$_____. ___
( 7600 )
PRINTING:
FOR:____________________________________________________________________________
$_____. ___
( 7630 )
(OTHER)____________________________________________________
Other (Detail Required)$ _____. ___
(
)
(OTHER)____________________________________________________
Other (Detail Required)$ _____. ___
(
)
GRAND TOTAL: $______. ___
( 1010 )
________________________________
Your Signature
Attach Your Receipts to the Reimbursement Request and mail to:
Ohio AOH State Secretary
Ron Hagan
480 S. 3rd St.
Columbus, OH 43215
FOR SECRETARY’S USE ONLY
DATE______________________
VOUCHER # ________________
AMOUNT $_________________
REV 07-25-2009
Ronald J. Hagan, Secretary, Ohio State Board