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"
Rows
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
Should be Empty: