OA Region One
EXPENSE REIMBURSEMENT FORM
Member Name
*
First Name
Last Initial
Phone Number
*
Format: (000) 000-0000.
E-mail
*
Your E-mail Address
Please enter payee name and address for the Cheque
*
Street Address
Street Address Line 2
City
State
Zip Code
Expense Details
What is this expense for?
*
Please Select
Region One Assembly
Region One Convention
R1 WSBC Delegate
Board Outreach Visit
Intergroup WSBC Delegate
Intergroup WSBC Alt Delegate
Intergroup R1 Representative
Intergroup R1 Alternate Rep
Other Expenses (Board)
Other Expenses (Intergroup)
Event Details
Intergroup Name
*
Please Select
Alaska
Anchorage
Big Sky
Bitterroot
Catch the Wave
Central Oregon
Emerald Empire
Greater Seattle
Heart of Canada
Lake Country
Northern Lights
Oregon
Peninsula
Pierce County
Regina
Sea to Sky
Snake River
South Sound
Southeast Alaska
Southern Alberta
Southern BC Interior
Southern Oregon/Northern California
Vancouver Island
Event Name
i.e Assembly, IG Retreat, WSBC, IG Renewal...
Event Location
i.e Seattle, Albuquerque, IG Location, Virtual...
Please provide details about the Event.
Expenses (Registration, Hotel, Airline, Food...)
Other Expenses (excluding Mileage)
Rows
Purchase Date
Description (Hotel, Airline, Meals...)
Cost
1
2
3
4
5
6
7
8
9
10
Total Other Expenses
Mileage
Mileage List (Mileage calculated at a rate of $0.14)
Rows
OA Event Attended
Date of Travel
Miles Traveled
1
2
3
4
5
Total Miles Driven
Total Mileage Due (Miles x 14 cents)
TOTAL EXPENSES
Total Expenses including Mileage
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