Reimbursement Form

* Indicates required field

Month *

Day *

Year *

Brother/Pledge: *

First

Last

Committee/Position: *

Purpose/Use: *

Total Requested ($) *

Make to: *

Same as Above Other

If "Other", Who is payable? *

Phone Number *

Email *

Additional Comments *

I do hereby understand by Clicking "I agree" and also clicking the "Submit" button below and are electronically signing your name into the record, I will not be reimbursed for the amount above unless approved by the finance committee. This electronic record is enforced by: Section 7 of UETA: LEGAL RECOGNITION OF ELECTRONIC RECORDS, ELECTRONIC SIGNATURES, AND ELECTRONIC CONTRACTS. (a) A record or signature may not be denied legal effect or enforceability solely because it is in electronic form. (b) A contract may not be denied legal effect or enforceability solely because an electronic record was used in its formation. (c) If a law requires a record to be in writing, an electronic record satisfies the law. (d) If a law requires a signature, an electronic signature satisfies the law. I understand that I will not be reimbursed for the amount above unless approved by the finance committee *

I Agree

Submit