NNPS Reimbursement form

Nordic Neuropediatric Society

- a collaboration between the neuropediatric societies in the Nordic countries

NNPS Reimbursement form

NNPS Reimbursement Form

 

Please send the completed form with receipts to: Charlotte Reinhardt Pedersen, NNPS treasurer, Sötoften 8, Ramlöse Sand, DK -3300 Fredriksvaerk, Denmark, crp@dadlnet.dk, +45 22447226

 

 

 

Name………………………………………………………………………………………………………………………

 

 

 

Address……………………………………………………………………………………………………………………

 

 

…………………………………………………………………………………………………………………………….....

 

 

………………………………………………………………………………………………………………………………

 

 

Bank details

Name of bank………………………………………………………………………………………………………………………

 

 

Address……………………………………………………………………………………………………………………

 

 

………………………………………………………………………………………………………………………………

 

Account number……………………………………………………………………………………………………………………

 

 

IBAN………………………………………………………………………………………………………………………

 

 

SWIFT……………………………………………………………………………………………………………………

 

 

Purpose…………………………………………………………………………………………………………………

 

 

Receipt Nr Item Amount (currency) Amount (Danish kroner)

 

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1

 

____________________________________________________________________________

2

 

____________________________________________________________________________

3

 

____________________________________________________________________________

4

 

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Total amount (Danish kronor).......................................................................

 

Date Signature

 

 

 

 

 

 

NNPS treasurer authorized Date Signature

 

 

 

 

 

 

NNPS

Nordic Neuropediatric Society