REQUEST FOR REIMBURSEMENT 

NAME: ___________________________________________________________

DEPARTMENT: ____________________________________________________

ACCOUNT #: __________________________ P. O. #: _____________________

DESCRIPTION OF PURCHASE: (attach receipts)

____________________________________________________________            ________________

____________________________________________________________            ________________

____________________________________________________________            ________________

____________________________________________________________            ________________

____________________________________________________________            ________________

                                                                                                           TOTAL:            $_______________

I certify that the above expenses are true and correct and were incurred by me in the performance of my official duties in accordance with the policies of the Board of Regents.

________________________________________________________          _________________

SIGNATURE                                                                                                                          DATE

________________________________________________________          _________________

DEPARTMENT CHAIRPERSON/SUPERVISOR                                                                DATE

________________________________________________________          _________________

DIVISION HEAD                                                                                                                  DATE 

NOTE: Reimbursement will not be made for sales tax.

SPC Tax Exemption No.: 1-75-6004667-8