Lavington PAC Expense Reimbursement Request Form
Name
*
First Name
Last Name
Phone Number
*
Format: (000) 000-0000.
E-mail
*
Your E-mail Address
Is the name provided above the same as the one that the reimbursement cheque should be issued to?
*
Yes
No
Name to appear on reimbursement cheque
First Name
Last Name
Expense Details
What are these expenses related to?
Provide a description of the event and/or reason.
Has this expense been previously approved by PAC?
*
Yes
No
Unsure
Approval not required
Expenses List
Rows
Purchase Date
Description
Cost
1
2
3
4
5
Total Cost ($)
Upload *ALL* expense receipts
*
Browse Files
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Choose a file
Cancel
of
NOTE:
Expenses will not be reimbursed without proof of purchase.
Submission
I certify
I certify that all information entered above is valid and true.
Signature
Date
-
Month
-
Day
Year
Date
Submit
Should be Empty: