North Atlantic Health Sciences Libraries, Inc. Check Request

Committee: _______________________________ Date Submitted: ______/_______/_____

Check made payable to: ________________________________________________________

Address: ____________________________________________________________________

____________________________________________________________________________

____________________________________________________________________________

___________________________________________________________________________

Check Amount: _________________ Date Expenses Incurred: _____/_______/_____

Explanation of expenses:________________________________________________________

____________________________________________________________________________

____________________________________________________________________________

Check requests should be submitted to the Treasurer within 30 days of the expenditure –or- contact should be made with the Treasurer to explain why a delay is in order.

To be completed by the Committee Chair:
(If several different sub-accounts are involved indicate the amount requested for each, otherwise, check the appropriate sub-account.)
SUBACCOUNTS:

______ Equipment ______ Meeting expenses ______ Speakers ______ Supplies ______ Scholarship ______ Travel* ______ Hotel ______ Telephone ______ Refund ______ Postage

* (As of 1/1/07, travel will be reimbursed at 48.5 cents per mile. Mileage reimbursement should specify miles traveled and include receipts for tolls.)

Committee Chair signature:_____________________________________________

To be completed by Treasurer: Check number _________ Date _______

Send completed form to:
Mark Goldstein, NAHSL Treasurer
University of Massachusetts Medical School
NN/LM 222 Maple Ave.
Rose Gordon Building
Shrewsbury, MA 01545-2732
Phone: 508-856-5964
FAX: 508-856-5977
E-mail: mark.goldstein@umassmed.edu