Reimbursement Request Form
Request does not guarantee reimbursement.
DateTime
-
Month
-
Day
Year
Date Picker Icon
1
2
3
4
5
6
7
8
9
10
11
12
:
Hour
00
10
20
30
40
50
Minutes
AM
PM
AM/PM Option
Company Name
*
Please Select
Legacy Classical Christian Academy
Full Name
*
First Name
Middle Name
Last Name
Year
*
Month
*
Please Select
01
02
03
04
05
06
07
08
09
10
11
12
Department
*
Please Select
Curriculum for students
Curriculum for teachers
Office supplies
Science supplies
Materials needed for activity
Hospitality/food
Requested by admin
Other
Pls state Dept here if you have selected "OTR"
1
Purchase Date (MM.DD.YY)
Store Name
Amt Requested
01
02
03
04
05
06
07
Back
Next
Upload Receipts
*
Upload a File
Take a photo of the receipt and upload it here.
Cancel
of
Total Amt Requested
*
I certify
*
I certify that all information entered above is valid and true.
Remark: Please Print Form First Before Submit Form (Print Horizontal and Double Sided)
Submit Form
Print Form
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