2014 Student Leadership Conference Reimbursement

International Students

Directions: Please read this information carefully. Complete this form by typing your information in
the sections below, saving and submitting as directed.

IMPORTANT: All expenses must be submitted by 17 November
2014 or you forfeit your right to receive the funds

OSA will send the wire transfer by 21 October if this form is
submitted to chaptersandsections@osa.org by 30 September.
Note: It may take up to two weeks for the funds to appear in your
account. All requests submitted after 30 September will be
processed on or after 28 October.

Please review the following:
OSA will only reimburse flight and visa fees up to $2,000 USD.
Retain copies of all receipts.
OSA checks all receipts.
OSA automatically pays for the conference hotel for 18-19 October. Note:
o You must book through the OSA travel service, Travel Planners.
o Travel Planners will assign a hotel for you.
o OSA will not pay for a) additional nights, b) other hotels not assigned to you or c) if you
do not reserve through Travel Planners.
OSA cannot accept hand-written expense reports.
FiO registration has been paid directly by OSA.

Follow these instructions for each section of the form:
Section 2: Call your bank to obtain the correct wire information.
Section 3:
o Ignore the US Dollar (OSA Internal) fields.
o Do not total your expensesOSA will do this for you.
o In the Amount and Currency column, indicate which currency was used for payment,
and record expenses in the currency in which it was paid (e.g., , , ); OSA will convert
the currency.
o Check the boxes to verify your information.
Section 4: Ignore.

When completed, submit the form and scanned receipts to chaptersandsections@osa.org. OSAs bank
will initiate wire transfers a maximum of two times; if wires are returned twice, payment will be made
by check.

Mailing address:
If you wish to send your form/receipts by mail instead of emailing them to
chaptersandsections@osa.org, please send them to:
The Optical Society
ATTN: John Taylor, Student Leadership Reimbursement
2010 Massachusetts Ave. NW
Washington, DC 20036


Examples of eligible expenses:
Airfare, baggage fees
Visa fees

Examples of ineligible expenses:
Passport fees
Visa fees, if the visa is denied
Visa transportation fees
Transportation fees
Food
Calling card

2014 Student Leadership Conference Reimbursement Form
International Students

Section 1: Personal Information
Name:

Street:


City/State/Province:

Country:

Postal Code:



Section 2: Wire Transfer Form (Contact your bank to confirm this information)
1. Please provide the complete mailing address for your bank and your account information:
Bank Name
Branch Name
Bank Mailing Address
Bank Swift Number
Name of Account Holder
Mailing Address of Account Holder
(if different from above)

Account Number/IBAN
2. Wire transfer is payable through the following US Bank:
NOTE: Unless asked, you do not need to complete the following section.
US Bank Name
Branch Name
Bank Mailing Address
Routing Number (ABA)
Account Number

ORKHONGUA BATJARGAL
NATIONAL UNIVERSITY OF MONGOLIA, IKH SURGUULI STREET 1, BAGA TOIRUU
ULAANBAATAR
MONGOLIA
14201
TRADE DEVELOPEMENT BANK
ERDENES SETELMENT CENTER
INFO@TDBM.MN INFO_TDB@YAHOO.COM
TDBMMNUB
ORKHONGUA BATJARGAL
GUARKHAN.1@GMAIL.COM
475010715
Section 3: 2014 Student Leadership Conference Expense Details
Expense Date Incurred Amount & Currency
Visa fees:
Air fare:
Total Non-US Currency (or USD):
I confirm all of the information provided is accurate.
I confirm that I have contacted my bank to verify this information.

Requestor Signature (please sign above).



Section 4: Approval and Payment (OSA Staff Only)
Convert to USD


Total USD Amount Due


Non-U.S. Currency to USD Rate
(up to $2,000 USD)
Conversion date

Print Approver Name Signature Amount Date

Print Finance Cashier Name Signature Amount Date

Business Purpose of Expense: 2014 Student Leadership Conference Reimbursement

OSA Cashier: Make a copy of this form for recipient; keep original, copy of check/wire information and all
supporting documentation. Finance Cost Code: 200-7450
19 AUG 2014 304000MNT
18 SEP 2014 2246500MNT
2550500MNT