NEW POLICY (You must fax receipt(s) to 480-598-9498 by the 10th or 25th. If we do not receive the receipt(s) by this deadline, PDI will not submit and hold your entire invoice until we receive the receipt(s). We will then pay your invoice on the next pay cycle.)
*Denotes optional fields.
Choose Your Supervisor:	---- Elise Kamiya Brad Funk Cheryl Cohen-Kelly Carl McGinn Amy Wade Andrea Case Holly Martin Tammy Dostal Other
Remit To:
Name:
Address:
City:
Zip:
State:
Phone:
*Fax:
Program Name:
Invoice Number:
Invoice Date:	May 20, 2012
Number of Days that services were rendered:	1-10 11-20 21-30 31-40
Are there any Costs Advanced to report: (All receipts MUST be be faxed to 480-598-9498 at the time of invoicing. Please include a proper cover letter, the program name, and your name on the receipts.)
No Yes
Mileage:
Payment Method:	---- Check (First Class Mail) Check (Fedex) Direct Deposit Wire Transfer