Reimbursement Form
Thank you for your effort to support NPLB Outdoors. This form is to be used for reimbursements to yourself or payment to a vendor. Multiple payments will require multiple form submissions. This form must be filled out completely and correctly. Receipts or proof of purchase must also be included. Please allow up to 7 business days for processing. Checks are sent via standard mail from Maryland and shipping times may vary. If you have questions or need faster payment, please contact adam@NPLBoutdoors.org upon completion of this form.
Invoice#
Are you completing this form on behalf of yourself or someone else?
I am completing this form on behalf of myself.
I am a staff member or volunteer submitting this form on behalf of a vendor or someone else.
This is an:
Invoice
Reimbursement
Pay to:
*
Who is being paid?
Amount due:
*
Total amount owed.
Phone #:
Payee's phone number
E-mail:
example: mike@yahoo.com
How would you like to receive funds?
*
Mail a check
I already have direct deposit set up
I would like to set up direct deposit (fill out bank fields below)
Enter a brief description of the item any why it was purchased:
Due date (if any)
-
Month
-
Day
Year
Date
Address
*
Street Address
Street Address Line 2
City
State
Zip Code
Name on Bank Account (not bank name)
Bank Routing Number
Bank Account Number
Please upload a copy of your receipt(s). Max size 5MB total.
Browse Files
Cancel
of
Please upload a copy of your business W-9, if applicable
Browse Files
Cancel
of
I certify that the information I provided on this form is correct and all items purchased were made on behalf of NPLB Outdoors. I understand that prior approval should be obtained before making such purchases and I could be responsible for expenses without prior approval.
*
Submitted by
*
First Name
Last Name
Submit Form
Should be Empty: