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 (Plymouth, Lyon, Hikari) 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.

Date of Purchase	Store Name with Description	Account Number	Location (Plymouth, Lyon, Hikari)	Cost