DCE PTO Reimbursement Form
To be submitted with photo of receipt for any approved charge or credit made by a PTO representative to be reimbursed by check.
Name Check Payable To
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Month
Please Select
January
February
March
April
May
June
July
August
September
October
November
December
Date Purchased
*
-
Month
-
Day
Year
Date
Date Submitted
*
-
Month
-
Day
Year
Date
Project/Category
*
Purchase Approval
*
Please Select
Approved in Budget
Approved in Meeting
Name of Vendor
*
Amount of Purchase
*
Upload Receipt
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Notes or Additional Comments
Please verify that you are human
*
Submit
Should be Empty: