HTML Preview Student Reimbursement Form page number 1.
■ Please enter all requested information excluding information in sections marked “For Office Use”
■ Attach corresponding invoices or itemized/original receipts
■ If you are being reimbursed for personalized t-shirts, mugs, etc., you must attached the design approval email
■ When completed, please print and bring to the office of University Student Affairs/COMP-Northwest Student Affairs
■ You will receive an email when the direct deposit has been processed or when your check is ready for pick up
■ Direct deposits will be posted to your personal bank account in approximately one week
■ Receipts should be submitted within 10 days of the purchase. Travel receipts within 30 days of travel (and by June 15th)
Pay from –or- Transfer from:
Class/Club Name: Fund #
Pay to (Print Name of Company or Individual):
Address
City State Zip Code
Telephone Student ID# @
Transfer to Class/Club (Print Name): Fund #
Please process my reimbursement as: Direct Deposit OR Check Mail Check to Payee (address must be provided)
(Preferred)
Return Check to University Student Affairs (California)
Return check to COMP-NW Student Affairs (Oregon)
Description of Purchase/Reason for Transfer Amount
Total Spent:
Total to be Reimbursed:
Signatures
I hereby certify that the above goods, services or expenses have been received, rendered or incurred to my satisfaction. Invoice(s) and/or itemized original receipt(s) are attached.
Signature of Club/Class President Print Name Date
Signature of Club/Class Treasurer Print Name Date
4099 70850 40 $
Pay/Transfer from Account Name Fund Org Account Program Prior Account Balance Date
4099 70850 40 $
Transfer to Account Name Fund Org Account Program Prior Account Balance Date
Travel Only:
Signature of USA/COMP-Northwest Student Affairs Representative Date Date Student Travel Notification Form Approved
Student Reimbursement Form
PAYER INFORMATION
PAYEE INFORMATION
FOR OFFICE USE
(Required if funds are payable to a student)
Event/Guest Speaker Name: Date: