Expense Form

1
Employee Name* This field is required.
First Name
Last Name
2
Date of Fuel Purchase* This field is required.
Date
Year
Month
Day
3
Gas Station* This field is required.
4
Vehicle* This field is required.
Blue - 2016 F-150
Gray - 2020 Ford Ranger
White - 2020 Ford Ranger
Black - 2019 F-150
Red - 2019 Ford Ranger (Sales)
Rental Truck
5
Odometer* This field is required.How many miles on the vehicle when fuel was added?
6
Odometer Accuracy* This field is required.Was the odometer reading exact or estimated?
Exact
Estimated - I'll do better next time
7
How many gallons?* This field is required.
Include decimals; do not round
8
Receipt Total ($)* This field is required.
9
Cost per Gallon
Auto-calculated
10
Last 4 digits of card used for purchase* This field is required.
11
I certify* This field is required.
I certify that all information entered above is valid and true.
12
Upload Receipt Here* This field is required.
Drag and drop files here
Select files to upload
Max. file size: 15.5MB
Cancelof
13
Please verify that you are human* This field is required.
14
Signature* This field is required.
Clear
Should be Empty: