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Request for Reimbursement
This form should be completed for expenses incurred by member and for orders placed to be invoiced to MAEA.
Email address *
Expense Details
Title of Project/Activity *
Provide name of the workshop, activity, and provide year. (i.e. Paper Weavings, Fall Conference 2015)
Total Expenses *
Itemized Description of Program/Activity *
Receipts or invoices are required and must be uploaded to the folder with this submission before payment will be made.
Date Submitted *
MM
/
DD
/
YYYY
Name *
Member Making Request
Payable To:
Provide below the name and address of the person or institution to reimburse.
Check Payable to *
Street Address *
Street Address Line 2
City *
State *
Postal/Zip Code *
Email *
Phone *
(XXX) XXX-XXXX
File Upload - Please upload your receipts here.
File Upload - Please upload your receipts here. *
Required
Digital Signature
Check the box below and enter your name to provide your digital signature.
*
Required
*
A copy of your responses will be emailed to the address you provided.
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