Employee Quality of Life Reimbursement Request Form
Submit your request for reimbursement of approved quality-of-life expenses. Please provide accurate details and supporting documentation.
Full Name
*
First Name
Last Name
Work Email Address
*
example@example.com
Department
*
Please Select
Engineering
Product
Design
Marketing
Sales
Operations
HR
Finance
Other
Expense Category
*
Please Select
Wellness (Gym, Fitness, etc.)
Mental Health
Work-from-Home Equipment
Learning & Development
Transportation
Other
Expense Description
*
Expense Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Expense Amount (USD)
*
Upload Receipt or Proof of Expense
*
Upload a File
Drag and drop files here
Choose a file
Cancel
of
Manager or Supervisor Name
*
Internal Reference or Notes (if any)
Submit Request
Should be Empty: