PHILADELPHIA CONNECTIONS EP INVOICE FORM
Please complete all items with an asterisk (*) AND PRINT!
*Date
this invoice is being completed:
Date and/or time
period of services: (include
beginning and end dates if not a single date of service)
First semester—September through
December, 2011
Services provided:
(Please
describe what was provided and for how long for example: "Two 3-hour seminars on
Psychotherapy")
First
semester stipend for MSW Enhanced Placement program___ _
Costs for Services
Provided:
Please specify amount of services,
rate of pay, and total amount due--for example,
"Two seminars at $100.00 per
seminar = $200.00 Total"
***If expenses for materials, travel, etc. have been agreed
upon, please attach original bills or invoices.
One semester @ $250.00/semester
= TOTAL:
$ 250.00
INFORMATION FOR PURPOSES OF
REIMBURSEMENT/PAYMENT:
*Name
of person or agency being paid:
Function of person being
paid:
Enhanced Placement student
*What address
should the check be mailed to?
*Phone Number of
person receiving check:
*Social Security
Number of person receiving check:
*Name
and phone number of person to contact about problems with invoice--if
different than the person receiving check (otherwise,
leave blank):
___________________________________________
(__ __ __) __ __ __ - __ __ __ __
Name
Phone
Questions about completing this form?
Call
Luciane Green: 215-599-5176
Please do not write below this line.
__________________________________________________
____/____/____
Coordinator, Philadelphia Connections
Date
Invoice for: EP
School/provider/note_____________________________________________________________________________________
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