Check_Request_Form

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NORTHEAST ZONE of
WASHINGTON STATE HORSEMEN
Reimbursement Request Form
Payable to: _________________________________________ Date: ______________
(Include First &Last Name)
Mailing Address: ________________________________________________________
City: __________________________ State: _______________ Zip: _______________
Item Purchased: __________________________________________________________
Amount to be reimbursed (attach receipt): _____________________________________
NEZ Division: (circle the appropriate area responsible for this expense)
General Fund
Games
Horse Show
Trails & Pleasure
Youth Merit
Authorized/approved by: __________________________________________________
(Division Chairman Signature)
If expense is to come out of the ‘General Fund’, date of meeting that payment was
approved: __________________________________________
Submit completed request to: Cheryl Moriarty, NEZ Treasurer
26728 W. Tucker Prairie Rd
Cheney, WA 99004
Or scan/e-mail to: [email protected]
Reimbursements requests submitted without the Division Chair’s approval/signature may
be delayed/returned for completion.
Treasurer use:
Date paid: ______________________________
Check #: _______________________________
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