SC - Reimbursement Request Form
If you have multiple receipts, please compile them into one request form.
Name
*
First Name
Last Name
Address - check will be mailed to this address (include apartment number if applicable)
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
*
example@example.com
Are you an employee on campus? (Paid coaches, answer "yes")
*
Yes
No
Are you a US citizen?
*
Yes
No
Club Name:
*
Total Reimbursement Amount:
*
If you have multiple receipts, please combine the total.
Description of Reimbursement(s):
*
Please describe all receipts and separate them by semi-colons (;).
If you are requesting reimbursement for gas, is it for a personal or rental vehicle?
Personal Vehicle
Rental Vehicle
Other
If it was a rental vehicle, who's card where the rental car charges put on?
This is likely your team's travel card holder or your designated Sport Club Professional.
Date of Expense(s):
Please separate dates with a comma.
Itemized Receipts
*
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Picture of Credit Card Used:
*
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Black everything out EXCEPT your name and the last 4 digits. The last 4 digits on this card must match the receipt. If you used multiple cards, submit pictures of all of them. NOTHING ELSE WILL BE ACCEPTED.
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Picture of Bank Statement Showing Your Name AND the Associated Charge:
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This MUST be a picture of your bank statement showing the charge(s) AND your name. NOTHING ELSE WILL BE ACCEPTED.
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If the reimbursement request is travel or food related, please upload a roster of those in attendance at the event. This may be a screenshot from DSE.
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Signature
Admin Notes:
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Submit
Should be Empty: