D ate
S ubmitted:_____________
SEC
R eimbursement
F orm
Please
f ill
o ut
t he
i nformation
b elow
i n
i ts
e ntirety
t o
r eceive
a
r eimbursement.
I n
addition
t o
c ompleting
t his
f orm,
y ou
m ust
i nclude
t he
r eceipts
f rom
y our
p urchases.
Please
e -‐mail
t his
f orm
a nd
t he
r eceipts/invoices
t o
t he
c urrent
D irector
o f
P hilanthropy.
General
I nformation
N ame
( First
a nd
L ast)_________________________
E-‐mail___________________
Organization/Department__________________________
Total
A mount
R equested
f or
R eimbursement____________________
Reimbursement
t ype
a nd
s emester/year
o f
a ward
( Engineering
O rganization
F und,
Design
T eam
E ndowment,
B ig
C ontribution)
E x.
E OF,
F all
2 012
___________________________________________
For
E ngineering
O rganization
F unds
o r
B ig
C ontribution:
Payee
N ame(s)_____________________________________________________
E-‐mail____________________________________________________________
Address
o f
o ffice
l ocation
( where
c heck
c an
b e
m ailed
i f
n ecessary)
__________________________________
__________________________________
For
D esign
T eam
E ndowment:
Department/Fund
n umber
( unique
t o
y our
d esign
t eam)____________________