Respondent Reimbursement Form Respondent Reimbursement Form If you are human, leave this field blank. Respondent Name Respondent Email Work Phone Cell Phone Send Reimbursement to: Address Line 1: Address Line 2: City: State Zip Production Information: Production/s seen: Date/s: Location/s: Travel Information (receipts required): Total Miles Personal car/gas expense @ $.40 per mile) Tolls Parking Taxi Plane fare Total: Mapquest or googlemaps link here Please check all that apply: Associate Production(s): Online Response sheet(s) completed? Yes N/A Participating Production(s): Online Response sheet(s) and Written Response sheet completed? Yes N/A I have sent my receipts via "snail mail?" Yes N/A Upload scanned receipts (one file per box): Drop a file here or click to upload Choose File Maximum upload size: 256MB Drop a file here or click to upload Choose File Maximum upload size: 256MB Drop a file here or click to upload Choose File Maximum upload size: 256MB Drop a file here or click to upload Choose File Maximum upload size: 256MB Note that reimbursement will not be made until all required response forms have been received. Send receipts via mail to Bill Gillett Chair, Region II Howard Community College, Arts & Humanities 10901 Little Patuxent Pkwy Columbia, MD 21044 Additional Comments
