Affiliated Chapter *

Select your Affiliated Chapter

Enter required value Delaware Georgia Maryland Montana Texas Virginia

Request Summary *

Enter a summary of the requested payment (e.g. Payment for Speaking Services or Reimbursement to NAME for Chapter event).

Payment Amount *

Enter the value to be paid

Payment Type *

Select the type of requested payment 

Enter required value Reimbursement (PERSONAL) - Check Payment Reimbursement (CHAPTER) - Online Transfer Pending Payment/Invoice - Online Credit Card Payment Request

Payment Recipient *

Enter the name and address of payee (reimbursement) or invoice/payment processing for pending payments (credit card)

Payment Documentation *

Attached an invoice, letter of engagement, or any applicable documentation to support the payment. Payment requests without documentation will be denied based on signed Banking Agreement. 

20MB max

Additional Documentation

Optional. Only if additional uploads are needed.

20MB max

Additional Documentation

20MB max

Submitter Name *

Enter First/Last Name of Submitter

Email *

Enter email of submitter

Acknowledgement *

I acknowledge and affirm the submitted payment request is consistent with Chapter business and is an eligible expense. Further, I have the authority and/or approval of the selected Affiliated Chapter to complete this submission, and acknowledge that all entries will be provided to the chapter president, if not the submitter, to support checks and balances. Any alleged or confirmed falsified submissions shall be sent to the local chapter for assessment for criminal investigation.