Caution: uncheck this box if you are on a public computer (e.g. Hotel, Coffee Shop)
Request Membership For the EHPTSA Enrichment Program
* indicates a required answer.
This form is to be submitted for reimbursement for previously agreed upon budget items.
Please complete and submit the following form, after submission turn in your receipts to the EHPTSA treasurer.
Reimbursement Request Date: (MM/DD/YYYY)
Mailing Address if reimbursement check is to be mailed:
Less Cash Advance:
By Checking This Box I am Signing my Signature To This Expense Reimbursement Fund To Be Reimbursed For Previously Approved Budget Items: