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* 1. Date

Date / Time

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* 2. Submitted From (Your Full Name)

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* 3. Email Address

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* 4. Phone Number

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* 5. Your Organization's Name

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* 6. Pay to the Order of

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* 7. Mailing Address (check will be sent to)

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* 8. First Expense Detail

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* 10. Attach receipts or documents (#1)

DOCX, DOC, JPEG, JPG, PDF, PNG file types only.
Choose File
No file chosen

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* 11. Second (2nd) Expense

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* 13. Attach receipts or documents (#2)

DOCX, DOC, JPEG, JPG, PDF, PNG file types only.
Choose File
No file chosen

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* 14. Third (3rd) Expense

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* 16. Attach receipts or documents (#3)

DOCX, DOC, JPEG, JPG, PDF, PNG file types only.
Choose File
No file chosen

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* 17. Fourth (4th) Expense

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* 19. Attach receipts or documents (#4)

DOCX, DOC, JPEG, JPG, PDF, PNG file types only.
Choose File
No file chosen

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* 20. Total Amount

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* 21. Notes (Will this check be picked up?)

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* 22. E-Signature (Final step to verify your submission)

T