DATE: ____________________
PAYABLE TO:
NAME: _____________________________________________________
ADDRESS: _________________________________________________
__________________________________________________
PHONE: ____________________________________________________
EXPLANATION OF PURCHASE: _________________________________
__________________________________________________________
__________________________________________________________
__________________________________________________________
AMOUNT OF REIMBURSEMENT: ________________________________
Smithtown Stitchers Reimbursement Form
OFFICE USE:
DATE: _________________
CHECK #: ______________
TREASURER SIGNATURE: ______________________________________
** IF YOU WOULD LIKE YOUR REIMBURSEMENT CHECK MAILED TO YOU,
PLEASE PROVIDE A SELF ADDRESSED, STAMPED ENVELOPE. THANK YOU.