NATIONAL COUNCIL OF STATE BOARDS OF NURSING (NCSBN)

111 E WACKER DRIVE - SUITE 2900 BUSINESS EXPENSE REIMBURSEMENT FORM Instructions:
CHICAGO, IL 60601-4277 Refer to NCSBN travel policy for delineation of reimbursable expenses. Submit
Business Expense Reimbursement Form within two weeks of completion of trip. Retain
DATE a copy for your records. Receipts must be attached for all expenses paid by traveler
which exceed $25.00
NAME MAKE CHECK
PAYABLE TO EXPENSE SUMMARY
PURPOSE OF EXPENSE ADDRESS
TOTAL EXPENSES $0.00
MEETING CITY STATE ZIP LESS EXPENSES BILLED TO NATIONAL
$0.00
LOCATION COUNCIL

EXPENSES BILLED TO NATIONAL COUNCIL:

LESS CASH ADVANCED
MEETING DATE TOTALS
AMOUNT DUE TRAVELER OR NATIONAL
$0.00
Airfare, Bus, Rail $0.00 COUNCIL
Lodging $0.00
Meals: Breakfast $0.00 EXPLANATORY REMARKS *
Lunch
$0.00
Dinner $0.00
Shuttle/Taxi $0.00
Other:* $0.00
$0.00
$0.00
Subtotal $0.00
I certify that this statement is accurate as to actual and necessary business expenses
incurred.
EXPENSES PAID BY TRAVELER:
Airfare, Bus, Rail $0.00 Signed
Lodging $0.00
Meals: Breakfast $0.00 Date
Lunch Month Day Year
$0.00
Dinner $0.00 NCSBN USE ONLY
Shuttle/Taxi $0.00 APPROVAL SIGNATURE DATE
Telephone $0.00
Parking, tolls $0.00 ACCOUNTING SIGNATURE DATE
Mileage $0.00 $0.00
Honorarium or other fee $0.00
Other:* $0.00 EXPENSE COST CENTER AMOUNT
$0.00
$0.00
Subtotal $0.00
TOTAL EXPENSES $0.00

* Explain under Explanatory Remarks

Form Revised Date 3/19/2010