Payment Authorization & Reimbursement

Expenses*

Rows	Date	Amount ($)	Product/Service Description	Vendor/Store name
1
2
3
4
5
6
7
8
9

Total Amount ($)*
auto calculated
Receipts

Files under 1MB work best! Please make sure all amounts, descriptions, vendor names are clearly legible.
Cancelof
Delivery Instructions
Mailing Address*

Name

Street Address

CityState / Province

Postal / Zip Code
Other (Instructions)*
- Check#
- Check Issued
  
  MonthDayYear
- For Treasurer Use ONLY
  
  Please click the SAVE button after entering check information.
  
  Do NOT resubmit the form.
- Should be Empty:

PAYMENT AUTHORIZATION & REIMBURSEMENT FORM