NOTA PER LAVORATORI AUTONOMI NON RESIDENTI

THE SECOND CEPR-MODENA CONFERENCE ON GROWTH IN MATURE ECONOMIES
MODENA, NOVEMBER 7-8, 2013
EXPENSE CLAIM FORM
Università degli Studi di Modena e Reggio Emilia
Dipartimento di Economia Marco Biagi
Viale Berengario 51, I-41121 Modena
Italy
First and last name of claimant:
Place of birth:
Institution:
Home address:
Telephone:
Italian Fiscal code:
Nationality:
Date
From/To
Date of birth:
Office address:
Fax:
Email address:
Foreign Fiscal Code (or Social Security Number):
TRAVEL EXPENSES CLAIMED:
Mode of transportation
Currency
Amount
Total
Please see reverse side
I declare that I am exempted from issuing an invoice since the expenses claimed consist of a
reimbursement.
I confirm that the expenses claimed have been actually incurred by me, solely for the above indicated
purposes.
The reimbursement should be transferred to my personal bank account, identified as follows:
Bank (name, city, country, address)
IBAN No.
SWIFT/BIC No. (only for non Italian accounts)
I declare that I will inform you of any change in the above information.
Date
Signed by claimant
PLEASE MAIL THIS FORM WITH THE ORIGINALS OF YOUR TICKETS, BOARDING CARDS AND RECEIPTS
TO: Silvia Minervini, Dipartimento di Economia Marco Biagi, Viale Berengario 51, I-41121 Modena,
Italy, phone +39 059 2056941, email [email protected] NO LATER THAN THREE WEEKS
AFTER THE END OF THE CONFERENCE.
PLEASE NOTE THAT TRAVEL EXPENSES WILL BE COVERED UP TO THE CEPR TRAVEL LIMITS (EUROPE €
450, U.S. EAST COAST $ 900, U.S. WEST COAST $ 1200), INCLUDING AIRFARES AND LOCAL/GROUND
TRANSPORT COSTS, UNLESS PREVIOUS AUHTORIZATION HAS BEEN OBTAINED.