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3710 University Drive Suite 140
Durham NC 27707

Phone: 919.956.9124
FAX: 919.682.1449

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Presented by:
North Carolina Coalition Against Domestic Violence
123 W. Main Street
Suite 700
Durham, NC 27701

Phone: (919) 956-9124

Please provide the following contact information:
*Required fields

Name(s) of Participants
(you can use the same form for more than one participant)
Street Address
Address (cont.)
example: 555-555-1212
Please list any dietary restrictions, accessibility requests or interpreting needs you may have:

NCCADV will be offering mileage reimbursement at $.565/mile on a first come, first serve basis. Those traveling over 150 miles will be eligible to receive reimbursement for overnight lodging up to $75, including all taxes and fees. If you are interested in either of these opportunities, please complete the information below. If you receive reimbursement for such expenses, you will be required to submit all paperwork within two weeks of incurring expenses and submit all necessary documentation.

Suggested hotels:
Holiday Inn Express 2701 Longpine Rd, Burlington, NC (336) 584-4447
Hampton Inn 2935 Saconn Dr, Burlington, NC (336) 584-8585
I would like to receive reimbursement for mileage while attending this symposium: Yes    No
I will be traveling miles to attend this training.
I would like reimbursement for overnight lodging:  Yes    No


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