REIMBURSEMENT APPLICATION FORM
TRANSPORT
MOOT 2013
APPLICANT’S IDENTITY (the information will be used to send the cheque)
Last name:
First name:
Address:
City:
Province:
Postal code:
Email:
Phone 1:
Phone 2:
MEANS OF TRANSPORTATION AND TRAVEL DETAILS OF THE APPLICANT
Bus (attach a copy of the proof of purchase)
Train (attach a copy of the proof of purchase)
Car, one reimbursement form per car (attach a copy of proof of purchase: car rental,
gas, ferry)
Departure address:
Departure city:
Departure date:
Arrival city: Ottawa
The traveled kilometers will be the shortest distance calculated by Google Maps.
Applicant’s name:
Date:
(if you wish to send this application form via email, please enter your name and date, acting as a signature)
Applicant’s signature: _____________________________________
________________
Date:
(if you wish to send this application form via mail or fax, please print first, then sign)
RETURN APPLICATION BEFORE SEPTEMBRE 16TH
By email:
contingent-moot2013@scoutsducanada.ca
By fax:
514 254-1946
By mail:
Association des Scouts du Canada - Moot 2013
7331, rue St-Denis
Montreal (Quebec) H2R 2E5
Section reserved to the Association
Kilometers to and from
0,40 $
other expenses 1
other expenses 2
other expenses 3
Total to reimburse:
0$