REIMBURSEMENT CLAIM FORM
**Please note reimbursement of expenses takes approx. 3-4 weeks after this form is received**
	Please complete this form, attach original receipts and return to
		Att: Alison Conway
		Program Manager The Fields Institute 222 College Street Toronto Ontario Canada M5T 3J1 (416) 348-9710 ext 3026 Fax (416) 348-9759
	Program:	Large Scale Nonlinear and Semidefinite Programming
	Date of Event:	Wednsday, May 12 to Saturday, May 15, 2001
	PRINT CLEARLY
	Name:
	Date of Stay:			Number of Days:
	Mailing Address:
	Travel Expenses
	Airfare	$
	Mileage	$		(@ .30/km)
	Other	$		(Identify)
	Local Expenses
	Accommodation	$		(Identify location)
	Per diem	$		($50/day for meals - no receipts required)
	Miscellaneous	$		(Identify)
	Signature:
	For Institute use only
	EXPENSES				PROMISED FUNDING:
		Foreign $	Canadian $		Amount:
	Travel	$	$		Details:
	Accommodations	$	$		(local, travel etc)
	Per Diem	$	$
	Miscellaneous	$	$
	Totals:	$	$	$
	Exchange Rate:	_______________		Amount Reimbursed	Staff Initials:__________________