Request for Reimbursement
Date
*
/
Month
/
Day
Year
Date
Name
*
First Name
Last Name
Email
*
example@example.com
Are you a Board, Committee Member or Contractor?
*
Board Member
Committee Member
Contractor
Board Position
Please Select
President
President-Elect
At-Large
Communications
Finance
Membership
Professional Development
Student Rep
Committee
Please Select
Communications
DEA
designXPO
Finance
Membership
NCIDQ
Programs & CEUs
Student Affairs & Emerging Professionals
(Please select the committee responsible for these expenses)
Contractor Position
Please Select
Chapter Administrator
Public Relations/Marketing
Other
Expenses
Expense Description
Date of Expense
Amount $
Vendor
1.
2.
3.
4.
5.
Total
Total amount of reimbursement?
*
Notes to Oversight Director/Finance Director (optional)
GL Codes/Class (for Administrator to fill out)
Do you have a mileage reimbursement?
*
Yes
No
Upload Receipt(s)
*
Browse Files
Drag and drop files here
Choose a file
Cancel
of
How would you like the disbursement?
*
Zelle
Paper Check
Email for Zelle payment
Address for Paper Check
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Save
Submit
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