Employee Reimbursement Form
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Employee Reimbursement Form
Name: ______________
Title: _______________
Employer: _____________
Dates of
Payment Method Purpose of Expenditure(s): Please give
Expense(s) (Out of Pocket or by detailed reasons for all expenditures.
Business/Corporate
Card)

#1
#2
#3
#4
Summary of Expenses
Description
(Date, Details,
Etc)
#1
#2
#3
#4
Expense Report Total

Air/Rail Ground Lodging Meals Other Total
Travel Trans

I certify these are valid business expenses.
Reimburse/Cardholder Signature: ______________________
Reimburse/Cardholder Name: _________________________
Prepared by (Print): __________________

Date: ________________

I have reviewed these expenses and I believe they are true and
accurate.
Approved by (Print): __________________

Date: ________________