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Please download this form (by clicking File, Download, Excel) and email it to finance@lreda.org.
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Name of Applicant
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Date of Award Note: Mileage reimbursement for personal car use is $0.14/mile as set by Congress.
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Amount of Award
You may claim the amount you actually spent on gas to drive the miles listed.
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Email Address
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Make check payable to:
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Postal Address
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Street
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City
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State/Province & Zip/Postal Code
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Phone Number
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Itemized Expenses :
(Use a separate line for each receipt)
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DATEEVENTDESCRIPTIONCOST50% Claimed
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$0.00
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$0.00
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$0.00
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$0.00
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$0.00
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$0.00
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$0.00
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$0.00
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TOTAL$0.00
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By applying for these reimbursments, I confirm I am an active participant in the Credentialing Scholarship program
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SignatureDate
Don't forget to attach receipts!
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OFFICE USE ONLY:
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Approval SignatureDate
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