Reimbursement/Payment Request Form
Date
*
-
Month
-
Day
Year
Date
Requestor
*
First Name
Last Name
Requestor Email
*
example@example.com
Name of Committee
*
Event Name/Service from Budget:
*
Is this request for reimbursement or payment to a vendor?
*
Reimbursement to Payee (append proper receipts)
Payment to vendor (append proper invoice/receipt)
Other
How do you want to receive the reimbursement?
*
Zelle
Check
Amount of Reimbursement/Check Amount:
*
Please provide Zelle Information (put N/A if not applicable)
*
Make Check Payable to (put N/A if not applicable):
*
Vendor Information:
*
Name of Vendor
Address
City
State / Province
Postal / Zip Code
Is this request within budget (if not, it must be approved by the Executive Board)
*
Yes
No
Name of Committee Chair
*
First Name
Last Name
President First Name
President Last Name
Treasurer First Name
Treasurer Last Name
Upload Receipts (if requesting reimbursement)
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