Purchase / Reimbursement Request
Form Instructions
Please be sure to select the related Budget Line below from the drop down menu.
Complete receipts are required for reimbursement. This can be a picture of a paper receipt, or a downloaded digital receipt.
Receipts must not be cut off and must contain the store name, date of transaction, and show proof of payment. You are welcome to black out any line items that were for personal purchase.
Picture files (e.g., jpeg) work best, but pdf files are acceptable.
Email
example@example.com
Do you need to request a Purchase or a Reimbursement?
*
Purchase
Reimbursement
Are you a Teacher or a PTA member?
*
Teacher/Staff
PTA Member
PTA Officer (President / VP / Secretary / Treasurer)
Which Officer are you?
Please Select
President
Vice President
Secretary
Treasurer
Your Name
*
First Name
Last Name
Your Email
example@example.com
Date
-
Month
-
Day
Year
Date
Phone Number
Please enter a valid phone number.
Payable to Name (Company Name)
Payable to Address (Company Address)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Payable to Phone (Company Phone)
Please enter a valid phone number.
Payable to Email (Company email)
example@example.com
Purchasing Details - insert link to item or items or Point of Contact needed to finalize the Purchase
Check Payable to:
First Name
Last Name
Check Payable Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Teacher Item Request
PTA Member Request
Estimated Cost
*
Justification
Receipt Upload - Image Files preferred, PDFs also accepted
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Signature
Continue
Continue
Should be Empty: