ISTITUTO NAZIONALE DI ALTA MATEMATICA FRANCESCO SEVERI
CITTÀ UNIVERSITARIA - 00185 ROMA
____.____.____
http://www.altamatematica.it e-mail: indam@altamatematica.it
Tel. 06.490320 – 06.4440665 – Fax 06.4462293
The undersigned ________________________________________________________________
STATES
place of birth ________________________________________date of birth___________________
country_______________________________________ city _______________________________
address__________________________________________________________________________
affiliation _______________________________________________________________________
________________________________________________________________________________
phone number _________________________e-mail _____________________________________
participating to the activity:
GDRE Grefi-Grifga – Research activity in ___________________________, _____/_____/2012.
ask for the reimbursement of travel expenses as below (please attach the original receipt):
Airline, train or bus tickets (If there is not enough space below, attach another sheet of paper) From ____________________ to ___________________ Date ___________ Price ____________
From ____________________ to ___________________ Date ___________ Price ____________
From ____________________ to ___________________ Date ___________ Price ____________
From ____________________ to ___________________ Date ___________ Price ____________
Total amount paid for Lodging € _____________
Bank details
bank name and address ____________________________________________________________
account number ________________________________________________________________
routing number (or swift code, bank identification number, IBAN) _________________________
Date, Signature
________________________________
CODICE FISCALE: 80126810581 – P.LE ALDO MORO, 5
