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 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict 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. Beginning DateEnding DateDescription of tripStart odometerEnd odometerMiles traveledBusiness milesMiles traveled minus 20 = Business milesMiles reimbursementBusiness miles X $0.56ParkingParking Beginning DateParking Ending DateParking TotalAttach Receipts Click or drag files to this area to upload. You can upload up to 5 files. WagesEvent NameEvent DateHoursHourly RateWages TotalPaystubSEIU Healthcare 1199NW has my current pay stub on fileSEIU Healthcare 1199NW has I-9 and W-4 on fileOtherDateItemOther 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 SignatureWebsiteSubmit