APDA Membership

AMERICAN POWER DISPATCHERS ASSOCIATION

National Board
Reimbursement Form

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Please fill out the form below and submit to the National Treasurer for reimbursement of expenses incurred.

Name:

Office:

Date of Expense:

Total Amount To Be Reimbursed:

Business Purpose:

By entering my name in the “signature” field of this document I certify that the requested
reimbursement covers only those expenses incurred for the aforementioned business purpose.

Signature:
Address:
City: State/Province: Zip:
Telephone: Email:

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