CDS Supply Reimbursement Request

CDS Supply Reimbursement Request
Client Name (the person who receives services):*

First NameLast Name
Employer Name (client, employer, or designated representative):*

First NameLast Name
Your Email Address:*
example@example.com
Your Phone Number:*
Please enter a valid phone number.
CDS Program Name:*
Select all supplies/services for which you are requesting reimbursement:*

Fax/Copier/Printer/CartridgeOffice SuppliesEmployee Training/CPRAdvertisingAttendant Supplies (gloves, masks, etc)Hepatitis B VaccinesCriminal History CheckOther
Fax/copier/printer/cartridge: enter amount requested:*
Type number only
Office supplies: enter amount requested:*
Type number only
Employee training/CPR: enter amount requested:*
Type number only
Advertising: enter amount requested:*
Type number only
Attendant supplies: enter amount requested:*
Type number only
Hepatitis B Vaccine: enter amount requested:*
Type number only
Criminal history check: enter amount requested:*
Type number only
Other: enter amount requested:*
Type number only
Total Amount Requested:*
Type number only
Please upload ALL receipts for requested reimbursements.*

Cancelof
Certification:

By signing below, I certify that the attached receipts are for items or services to be used solely in support of the CDS client and/or the CDS employer and solely to fulfill the requirements of the CDS program. Further, each item has been purchased at a reasonable price of adequate quality to meet program requirements. Further, the cost of these items falls within the amount allotted in my current CDS budget.
Employer Signature:*

Clear
Employer email address:*
Where you'd like the confirmation of your request to be sent.
Submit Date*

MonthDayYear
Date
Hour MinutesAM/PM Option
Should be Empty: