CLIPCO Expense Reimbursement/Check Request Form
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Full Name *
Check will be payable to this name.
Address *
Check will be mailed to this address. If you can pick up at Muir, put "Muir office". If you're at Miller, put "Miller".
Email address *
All communication and a .pdf copy of this request will be sent to this email address.
Date of expense *
School *
Description of Purchase *
Please list general description of expenses and purpose.

For instructional materials (Muir only), please enter a detailed description of the items (e.g. pens, stickers, fidget toys, etc).
Amount ($) *
If you have multiple receipts, please add up your total amount and list here.
Category *
See Category and Subcategory List here: If you have multiple expenses in different categories, you must submit a new form for each category.
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