Free Parent Education Presenter's Invoice - West Virginia

Parent Education PRESENTER'S Invoice

Presenter: ______________________________________________ Make check payable to: __________________________________ Address for remittance: _____________________________ Social Security or FEIN___________________ _____________________________ Phone (home): ______________________________ Phone (work):____________________________ Fax:__________________________ E-mail address:__________________________________________

Submit completed form to: Pepper Flenner WV Supreme Court of Appeals 1900 Kanawha Blvd. Building 1, Room E-100 Charleston, WV 25305

Class information: (ONE class per invoice) Date ___________ County ___________________________ Number: paid _____ waived _____

* Please check appropriate box below:
Bachelor's Degree ($100.00 per session) Masters' Degree ($115.00 per session) Doctoral Degree ($130.00 per session) Total Session Fees $______________

* Out-of-County Mileage (available only if traveling to present class outside of home county)
Home county: ___________________________ Round trip miles traveled _______ x $0.____ = Total mileage $______________

* Out-of-Pocket Fees (a receipt must be attached to receive reimbursement)
Amount due _________ Description _______________________________________

Out-of-pocket fees Add session fees, mileage, and out-of -pocket fees:

$ _____________

Total Due

$______________

Presenter's signature: (Must be in blue) ____________________________________________ Date:____________
Administrative office use only:

Approved: _____________________________________________________ Date: ________
SCA-FC-PE-604 (12/07)