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NTUUC Check Request & Reimbursement Form
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What is 4 + 2?
Date of this request:
✻
Month
Month
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Day
Day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
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26
27
28
29
30
31
Year
Year
2021
2022
2023
2024
2025
Name
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Committee / Office
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Telephone:
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e-mail
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Purpose:
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Brief Description
✻
Describe the purpose of the requested payment.
Total Amount:
✻
Make Check Payable to:
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Address
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Additional Address
City
✻
State
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Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
ZipCode
✻
Attach scan or photo of receipt if available
Files must be less than
2 MB
.
Allowed file types:
gif jpg png bmp pdf
.
Attach additional receipt if needed.
Files must be less than
2 MB
.
Allowed file types:
gif jpg png bmp pdf
.
Approved for payment:
Executive Director
President
Treasurer