ESPGHAN Office c/o Vienna Medical AcademyAlser Strasse 4, 1090 Vienna, Austria [t] 0043 (0)1 405 1383 26 [f] 0043 (0)1 405 8274 [e] [email protected] Expenses Claim Form Please return your form with receipts attached within 30 days of the meeting you have attended to: ESPGHAN Office, c/o Vienna Medical Academy Alser Strasse 4, 1090 Vienna, Austria Note: Payment will normally be made within 28 days from receipt of your claims form. Payments will be made via direct transfer to your bank account, please provide full details below. Claimant Name: Date: Claimant Address: Telephone: Email Address: Please indicate below what your expenses relate to i.e Committee duties, Council Meeting etc Event / Location: Reason for Attending: Date of Meeting: Arrival / Departure Date: Amount Expenses: For Administrative Use Only (EUR or indicate Cost Unit Please be precise: flight tickets, hotel (no. of nights), transport, etc. currency) TOTAL Please pay me in the following currency: IBAN Number: SWIFT/BIC Number: Account Name: Bank and Branch: Account Number: Sort Code: Claimant signature: _______________________________ Date: __________________________ ESPGHAN Office c/o Vienna Medical Academy Alser Strasse 4, 1090 Vienna, Austria [t] 0043 (0)1 405 1383 26 [f] 0043 (0)1 405 8274 [e] [email protected]