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2. EMPLOYEE REIMBURSEMENT FORM
4. Requestor Information
6. First Name*
7. Last Name*
9. Department*
   -- Select One --BuildingClerkCodeFinanceFire RescueHuman ResoucesITManagerParks and RecPlanningPublic WorksPYH MarinaWastewater
11. Reimbursement Information
13. Transaction Date*
    Transaction Date
14. Reimbursement Type*

    1. License/Professional Certification
    2. Supplies
    3. Equipment

    1. Training
    2. Travel
    3. Other
16. Amount*
18. Detailed description*
20. Account Number*
    -- Select One --Building 107-1000-524-40 (Travel)Building 107-1000-524-51 (Office Supplies)Building 107-1000-524-52 (Operating Supplies)Building 107-1000-524-54 (Subscriptions/Memberships)Building 107-1000-524-55 (Training)Clerk 001-0400-512-40 (Travel)Clerk 001-0400-512-51 (Office Supplies)Clerk 001-0400-512-52 (Operating Supplies)Clerk 001-0400-512-54 (Subscriptions/Memberships)Clerk 001-0400-55 (Training)Code 001-1100-524-40 (Travel)Code 001-1100-524-51 (Office Supplies)Code 001-1100-524-52 (Operating Supplies)Code 001-1100-524-54 (Subscriptions/Memberships)Code 001-1100-524-55 (Training)Finance 001-0500-513-40 (Travel)Finance 001-0500-513-51 (Office Supplies)Finance 001-0500-513-52 (Operating Supplies)Finance 001-0500-513-54 (Subscriptions/Memberships)Finance 001-0500-513-55 (Training)Fire Rescue 001-0900-522-40 (Travel)Fire Rescue 001-0900-522-51 (Office Supplies)Fire Rescue 001-0900-522-52 (Operating Supplies)Fire Rescue 001-0900-522-54 (Subscriptions/Memberships)Fire Rescue 001-0900-522-55 (Training)IT 001-0700-519-40 (Travel)IT 001-0700-519-51 (Office Supplies)IT 001-0700-519-52 (Operating Supplies)IT 001-0700-519-54 (Subscriptions/Memberships)IT 001-0700-519-55 (Training)Marina 401-1400-575-40 (Travel)Marina 401-1400-575-51 (Office Supplies)Marina 401-1400-575-52 (Operating Supplies)Marina 401-1400-575-54 (Subscriptions/Memberships)Marina 401-1400-575-55 (Training)Parks & Rec 001-1300-572-40 (Travel)Parks & Rec 001-1300-572-51 (Office Supplies)Parks & Rec 001-1300-572-52 (Operating Supplies)Parks & Rec 001-1300-572-54 (Subscriptions/Memberships)Parks & Rec 001-1300-572-55 (Training)Planning 001-0600-515-40 (Travel)Planning 001-0600-515-51 (Office Supplies)Planning 001-0600-515-52 (Operating Supplies)Planning 001-0600-515-54 (Subscriptions/Memberships)Planning 001-0600-515-55 (Training)Public Works 001-1200-541-40 (Travel)Public Works 001-1200-541-51 (Office Supplies)Public Works 001-1200-541-52 (Operating Supplies)Public Works 001-1200-541-54 (Subscriptions/Memberships)Public Works 001-1200-541-55 (Training)Village Manager 001-0300-512-40 (Travel)Village Manager 001-0300-512-51 (Office Supplies)Village Manager 001-0300-512-52 (Operating Supplies)Village Manager 001-0300-512-54 (Subscriptions/Memberships)Village Manager 001-0300-512-55 (Training)Wastewater 402-1500-535-40 (Travel)Wastewater 402-1500-535-51 (Office Supplies)Wastewater 402-1500-535-52 (Operating Supplies)Wastewater 402-1500-535-54 (Subscriptions/Memberships)Wastewater 402-1500-535-55 (Training)

24. 
    

    
    

    _______________________________

    Employee Signature / Date

25. 
    

    
    

    _______________________________

    Leader Signature / Date

27. Form must be printed, signed and submitted with receipts to Human Resources for processing.

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28. Print Only

* indicates a required field