You must have this formed signed with original signatures. Please print and send the signed form to:

Dr. Joe Kortz or Linda Creighton

Sam Houston State University

Teacher Education Center

Huntsville, TX 77341-2119

Request for Reimbursement- Consultant Services

Sam Houston State University

Name : ______________________________ Title: _____________________________

Mailing Address: _______________________________________

Social Security Number: _________________________________

Vendor ID or Tax Exempt#: ______________________________________

Description of Services: _________________________________________

I, the Consultant, certify the following:

1. That the above is true and correct.
2. That dual compensation is not provided, i.e., the individual may not receive compensation from his regular employer and the retaining grantee or subgrantee for the work performed during a single period of time even though the services performed benefit both.
3. That I am ___ am not_____ a full-time federal employeee, permission has been granted from my agency to accept reimbursement for documented travel expenses.

Signature of Consultant: _________________________________ Date: ____________________

Signature of Project Director _____________________________ Date: ____________________