Reimbursement Form

Mile City Reimbursement Form
*Please use this form for purchases that you need to be reimbursed for.
Make Check Payable To*
If mailing, please provide an Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Department Head*
Name of Person Submitting*
First Last
Email*
*Please attach all receipts. All reimbursements must be submitted within 30 days.
Itemized List*
Date of Purchase Store Name with Description Account Number Location (P=Plymouth, L=Lyon, H=Hikari, E=Espanol) Cost

Please fill in the columns with the correct info. Click + to add more rows. If you would like to split between accounts, please do a separate line for each account with the split total.
Please upload all receipts for purchases listed above.*
Drop files here or

Max. file size: 50 MB.
You may put multiple receipts on to one document. Each receipt does not need to be individually uploaded.

Mile City Reimbursement Form

Date of Purchase	Store Name with Description	Account Number	Location (P=Plymouth, L=Lyon, H=Hikari, E=Espanol)	Cost