CDS Supply Reimbursement Request

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

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

First NameLast Name
Employer Signature*

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