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)

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"

INFORMATION FOR PURPOSES OF REIMBURSEMENT/PAYMENT:

*Name of person or agency being paid:

Function of person being paid: Enhanced Placement student

*Name and phone number of person to contact about problems with invoice--if different than the person receiving check (otherwise, leave blank):

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Name Phone

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