Check # ___________

Check Date ______________

PCA REIMBURSEMENT REQUEST

Please note: Notify either Sharon Dershowitz or the coach/squad rep for your squad prior to purchasing items.  Failure to do so could result in reimbursement being denied.   Thank you.

Committee or Budget item: _________________________________________

Request date: _____________________

Total Receipt(s) Amount:  $_______________

Requested by: __________________________________________________

Approved by: ___________________________________________________

Purpose: _______________________________________________________

Payable to:  Name __________________________________________________

                         Address ________________________________________________

                         Phone __________________________

 Please attach all receipts to this form.

***Please include a self addressed stamped envelope for quicker reimbursement and send to:

Amy Tatro

4581 Kettering Drive

Roswell, GA 30075