Section on Perinatal Pediatrics
Airfare Reimbursement: Original ticket receipt must be enclosed. Speaker will be reimbursed coach
price with at least 14 days' advanced reservations made by the most economical route from point of origin
to the destination.
Ground Transportation: Original receipts must be enclosed. Speaker will be reimbursed for the most
appropriate means of ground transportation to and from the airport.
Meals: Speaker will be reimbursed with appropriate itemized receipts (no alcoholic beverages) if not
included in conference.
Incidental Expenses: Telephone, movies, faxes, bar, etc. are your responsibility.
Original itemized receipts must be supplied for expenses for which reimbursement is requested.
Name
Address
City
State
Zip
Social Security No.
Telephone No.
Fax No.
E-Mail Address
÷÷÷÷÷÷÷÷÷÷÷÷÷
Date
Expenses
Amount
$
Total Expenses $
Note: All fields of information must be completed on this form for accounting purposes. Any
missing information will result in the form being returned to you for completion, causing
delay of payment.
Please return to:
De-Ann M. Pillers, M.D., Ph.D., F.A.A.P.
Professor and Chief, Division of Neonatology
Department of Pediatrics
University of Wisconsin School of Medicine and Public Health
Meriter Hospital, 6-Center
202 S. Park St.
Madison, WI 53715
Thank you