Workshop Speaker Reimbursement Request

If you have any questions, please contact registrar@ismrm.org


Section 1

How would you like us to process your reimbursement? required


To change your selection, please reload the page.

Do you currently live in the USA? required

To change your selection, please reload the page.

Would you prefer to receive your stipend via mailed check or a Corpay transfer to your bank account? required

To change your selection, please reload the page.
Section 2: Your Information

Select the Workshop at which you spoke: required

Member #: required

First Name:   Middle Initial:   Family/Surname: required

Email: required
Section 3: US Mailing Information

Please provide your personal mailing address. Checks will not be mailed outside of the United States.
Street Address Line 1: required
Street Address Line 2: optional
Apartment/Unit Number: optional
City:   State/Province:   Postal Code: required
Section 3: Corpay

You will receive your reimbursement via Corpay

ISMRM has partnered with Corpay Cross-Border Solutions to send reimbursements to speakers. Corpay has a portal called Connections that facilitates our online payments directly to your bank account.

We will use the following information to create your Corpay account, or confirm an existing account. Please whitelist/allowlist email from Corpay.com so that you receive emails from them regarding this transaction.

Bank Account Owner's Information
Account Owner's Name required
First Name:   Middle Initial:   Family/Surname:
Account Owner's Current Home Address
Street Address: required
Street Address Line 2: optional
Apartment/Unit Number: optional
City:   State/Province:   Postal Code: required
Country: required
Account Owner's Email (if different from email you entered above):
Account Owner's Phone Number: required

Bank Information for Corpay Transfer required

The payment will be in your local currency; We do not send US Dollars overseas.
Local Currency:
Bank Name:
Bank Address:
Bank City:
Bank State/Province:
Bank Postal Code:
Bank Country:

The following fields vary by country.
If you are not sure which numbers your country and bank use, please check your bank's transfer requirements to be sure.

Bank Account or IBAN Number:
SWIFT/BIC:
Bank Routing Number:

Be sure all of your bank information is included and accurate!
Any missing details will lead to delays in payment and may require you to complete this form again.

Section 4: Receipt Uploader

Please Attach Your Receipt(s)

Please upload a digital copy of your itemized hotel receipt showing daily rate. We do not need the original.

  • Make sure the scan of your receipt(s) are readable. Scans made using a flatbed scanner or copier are preferred.
  • For multiple files, please combine them into a .zip file before uploading.
  • We do not recommend using a cell phone camera to copy documents, as focus and brightness are often poor and result in illegible text.

Attach your receipt(s) for upload here:

Accepted File Types: .zip, .jpg, .png, .pdf

The contents of this form are securely encrypted before transmission to the ISMRM Central Office.