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Reimbursement Request
Submit your information to request funding to support your organizing.
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* Indicates required question
Full Name
*
Your answer
Email Address
*
Your answer
Skype Name
Your answer
Phone number
best phone number for us to reach you
Your answer
Store Number
this is not required but would help us find resources for you
Your answer
Partnering Organization
Have you been working with OUR Walmart or others?
Your answer
What is this reimbursement for?
we will need reciepts
Groceries & Sundries (non food grocery items, ex garbage bags, toilet paper, first aid or cleaning supplies)
Car Maintenance
Electricity Bill
Cell Phone Bill
Rent Payment
Essential Clothing (ex. work boots)
Cable Bill
Your answer
Best Time to Reach You
6am-9am EST/EDT
10am-2pm EST/EDT
After 5pm EST/EDT
Best Days to Reach You
Weekends
Weekdays
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