Tri-Conference Reimbursement

Name

First

Last

of Please Signature

Phone

Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Rotary Club

Club Position

Reimbursement Amount?

Please note: Only the Conference Registration Fee will be reimbursed and only for current members of a Rotary Club within Rotary International District 9560.

Bank Details

Your reimbursement will be paid into the below bank account. Please verify that the details are correct.

BSB

Account Number

Account Name

Please upload a copy of your conference registration receipt

Drag & Drop Files, Choose Files to Upload

Signature

Clear Signature

By signing above, I confirm that the bank details provided are accurate. I understand that if incorrect bank details are supplied, my reimbursement may not be processed. I also confirm that all information provided in this reimbursement form is true and correct to the best of my knowledge.