Date____/____/____ Requested by:_____________________________________________

Phone:_____________________ Email:_________________________________________

Committee:________________________________________________________________

Group / Project:____________________________________________________________

Items Purchased / Description:__________________________________________________

_________________________________________________________________________

Total Amount: $______________________ (Please attach receipts to the back of this form.)

Make check payable to (print):_________________________________________________

Address:__________________________________________________________________

_________________________________________________________________________

Committee Chair Approved:___________________________________________________

Budgeted:                                        yes               no                                               (Circle one)

Mail this completed, approved form with receipts to:

Douglas Youngdahl
9027 South Fulton Ave.
Tulsa, OK 74137-3588

PLEASE NOTE: All requests for reimbursement must be accompanied by this form, and approved
by the committee chair.

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URI:/reimbursement.shtml

Date Modified:Monday, 05-Apr-2010 16:07:44 EDT

Friday, 10-Sep-2010 02:19:42 GMT