QPIRG Concordia Expense Form
Expenses
Date of Purchase
Expense Item Description
Amount Paid
Amount to be Reimbursed
1
2
3
4
5
6
7
8
9
10
Totals:
Please attach receipts or invoices for ALL expenses IN THE ORDER THEY ARE LISTED
*
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Please confirm that all receipts are attached and in order.
*
I double checked, I promise!
Working group name or budget line
*
Legal name of person being reimbursed
*
First Name
Last Name
Preferred name (if different)
First Name
Last Name
How should be make the payment?
*
Cheque, mailed
cheque, pick up in office
e-transfer
Other
Address (if you'd like us to mail the cheque)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email (if you'd like to be reimbursed by e-transfer or to notify when cheque is ready for pick up)
example@example.com
Signatures:
Two working group members must sign off on all expenses. One signature can be the person being reimbursed.
Endorser 1
*
Email address of second endorser
*
example@example.com
Submit
Submit
Should be Empty: