Scenic Cities Chapter

Emergency Nurses Association

Request for Reimbursement

Date ___________________________

Name ___________________________________________________________

Address _________________________________________________________

City _____________________________________________________________

State _______________________________ Zip _________________________

Purpose of Expenditure _____________________________________________

Amount Requested _____________________

Approval required by two members of Executive Committee. Attach original receipt.

Approved by ___________________________________________________

Approved by ___________________________________________________

Date paid __________________ Amount Paid $_______________

Method of Payment [ ] Petty Cash [ ] Check Number _____________

Paid by: _________________________________________________ Treasurer