IUBMB Reimbursement Form for IUBMB Meetings

IUBMB Advanced Schools

Meeting Title *

Location *

Number of days Meeting Attended *

Start Date of Meeting *

Year *

Month *

Day *

End Date of Meeting *

Year *

Month *

Day *

Total Amount *

USD

The total maximal amount is US $20,000

Bank Account Details

First Name *

Middle Name

Last Name *

Street Address *

Apartment, suite, etc

City *

State/Province *

ZIP / Postal Code *

Country *

Email Address *

Phone

Name of Account Holder *As spelled on the bank documents

Bank Name *

Bank Address *

Account Number *IBAN format for non-US banks

SWIFT / BANK / BIC *

ABA Code

*You will need to provide the full mailing address of the branch where the account is if you do not have any of the codes

Please note that 50% of the support is provided 3 months before the event, 20% is provided just before the event upon receiving the list of participants, and the remaining support of 30% will be paid once the meeting has successfully taken place and a report has been provided.

* I accept the payment terms.

Name of Organizer(s) *

Signature of Organizer *

Save as Draft