Wisconsin Academy of Family Physicians
Passport Program
Expense Reimbursement Form

Name:
Address:
City, State, Zip:
Phone:
Email address:


Check programs you visited:
Baraboo Rural Training Track
Columbia/St. Mary’s FMRP
Eau Claire FMRP
Fox Valley FMRP
LaCrosse-Mayo FMRP
Madison FMRP
Mercy Health System FMRP
Racine FMRP
St. Luke's FMRP
St. Joseph FMRP
Waukesha FMRP
Wausau FMRP

Expenses:
Total miles driven: @ $0.445 per mile = $
   Air, Bus, Train costs:
   Lodging costs:
   Meals cost:
Total Expenses requested: $
(Amount reimbursed will not exceed the scheduled maximum allowed based on the number of programs visited.)

If you are requesting reimbursement for mileage only, you may use the "Submit" button here or print and fax this form to WAFP at 262-242-1862.         

If you are requesting reimbursement for expenses other than, or in addition to, mileage,
please attach all receipts and return with this form to:
   WAFP,  210 Green Bay Road, Thiensville, WI 53092

Your check will be mailed to the above address after your visits have been verified.