Member Check Voucher Request Checks take up to two weeks to process. Please submit promptly to ensure timely reimbursement. Please enable JavaScript in your browser to complete this form.Name *FirstLastEmail *Address *Address Line 1Address Line 2City— Select state —AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeChapter/Hospital/Clinic *Date Submitted *I am a/an…Member organizerMember political organizerExecutive board memberExecutive board members are reimbursed their full rate only if they attend the entire meeting. Late arrivals and early departures will be deducted from your actual hours in 15 minute increments.Organizer Name *Check RequestI am submitting a request for reimbursement for: *MileageParkingWagesOtherReview our Member Expense Policy here.MileageRecord any mileage over 20 miles. Date RangeFromDate Range – ToToDescription of tripStart odometerEnd odometerMiles traveledBusiness milesMiles traveled minus 20 = Business milesMiles reimbursementBusiness miles X $0.70ParkingParking Date RangeFromParking Date Range – ToToParking TotalAttach Receipts Click or drag files to this area to upload. You can upload up to 5 files. WagesEventExecutive BoardOtherEvent NameExecutive Board Session AttendedMarch 13, 2025March 25-26, 2025 – Committee of the FutureApril 15-16, 2025May 16-17, 2025June 6, 2025 – Committee of the FutureJune 12, 2025 – Executive Board Chapter DayJune 24, 2025 – Committee of the FutureJuly 15-16, 2025August 7, 2025 – Committee of the FutureSept. 10, 2025 – Executive Board Chapter DayOct. 1, 2025 – Committee of the FutureOct. 14-15, 2025Nov 4, 2025 – Committee of the FutureDec. 5, 2025Dec. 6, 2025 – DLAEvent Date(s)FromEvent Date(s) – ToToShift Hours8 hours10 hours12 hoursOther:HoursTotal HoursAdd up the total hours you are requesting reimbursement for to cover lost wages.Hourly RateWould you receive premium pay for this shift? If so, list it below.(Night, evening, lead, preceptor, etc.)Wages TotalPaystubSEIU Healthcare 1199NW has my current pay stub on fileSEIU Healthcare 1199NW has I-9 and W-4 on fileIf not on file, upload pay rate documents Click or drag files to this area to upload. You can upload up to 2 files. OtherDateItemOther TotalAttach Receipts Click or drag files to this area to upload. You can upload up to 5 files. Grand TotalAdd total amounts highlighted in yellowGrand TotalWith my signature, I am confirming that I am not being paid by my employer in wages, vacation, or any other manner for the time that I have requested wages. I acknowledge that the hours entered are an accurate reflection of my attendance at the event listed above.Member Signature Clear Signature NameSubmit