Please provide the following information about yourself/agency

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* 1. TA Number (Leave blank if you don't know)

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* 2. Date 

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* 3. TA Recipient 

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* 4. TA Recipient Agency 

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* 5. Check Payable To

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* 6. Address check should be mailed to 

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* 7. City, state, & zip code 

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* 8. Your Email Address

*** Below you must enter the total amount of expenses incurred by your agency or self.  If HCET prepaid an expense enter 0. Before completing this section review email for approved invoice costs.  The email will be labeled Approved TA Request/HCET Invoice.***

Only enter numerical information into questions 8-15.  If no expense was incurred enter 0.

Upon completing this form please email all applicable receipts to Kadijha Marquardt-Davis (KMDavis@hcet.org)  or mail them to 6410 Enterprise Lane, Suite 100, Madison WI 53719. Please put to the attention of Kadijha Marquardt-Davis. Failure to send in your receipts will result in a delay in payment.

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* 9. Registration (receipts needed if not prepaid by HCET)

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* 10. Airfare (receipts needed if not prepaid by HCET)

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* 11. Hotel (receipts needed if not prepaid by HCET)

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* 12. Per Diem 

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* 13. Mileage (round trip mileage x 0.55 if below 149 miles OR round trip mileage x 0.50 if over 150 miles)

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* 14. Taxi/Shuttle (receipts needed if not prepaid by HCET)

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* 15. Parking (receipts needed if not prepaid by HCET)

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* 16. Baggage (receipts needed if not prepaid by HCET)

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* 17. Enter the total amount of expenses incurred from questions 9-16 (do not include expenses pre-paid by HCET)

This next section is for you to evaluate the conference you attended.  Please use complete sentences and thoughts.  

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* 18. List which conference topic area(s) were most valuable to you and why

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* 19. Were the agency/recipient goals met by attending this conference

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* 20. In what ways do you plan to apply the information and/or skills gained by participating in this conference

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* 21. Identify potential challenges you may have in using the ideas presented at this conference

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* 22. By entering my initials below, I certify that to the best of my knowledge this claim reflects allowable expenses incurred.

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