DMCMA Scholarship - Reimbursement Request OR Verification Request Form

Scholarship - Reimbursement Request or Verification of Attendance Form

DMCMA LYNNE CAMPEAU SCHOLARSHIP FUND
Name*

First NameLast Name
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Member of DMCMA?*

YesNo
Payment previously advanced?*

YesNo
Course Validation
Provider of Course*
Title of Course*
Dates Attended*

Expense List*

*Cost owed are to be paid within 30 days of program completion to:

DMCMA Treasurer, Juanita Sifuentes:

Phone : 509.574.1829

Email: Juanita.Sifuentes@co.yakima.wa.us

Yakima County District Court

128 N. 2nd St. #225

Yakima, WA 98901

Please attach invoice, receipts, MapQuest (PDF of route) and/or copy of Per Diem Rates *

Cancelof
MapQuest

Per Diem
How was this education beneficial:*
I cerifiy that the amount submitted for reimbursement or verification are costs incurred and I receivied prior approval to attend the program.
Signature of Applicant*

Clear
Date*

MonthDayYear
Date
Once submitted form will be forwarded to Scholarship Chairs for Approval.*
Scholarship Chairs
Should be Empty:

Scholarship - Reimbursement Request or Verification of Attendance Form