(If applicable. Please submit proof of successful
completion.)
APPLICATION FORM FOR
COURSE BOOK REIMBURSEMENT
Name:
Western ID
:
Date:
Faculty/Department:
Ext:
(Please include campus address - building name & room no.)
Name of course book:
Course name
:
Course Number
:
Educational institution:
Marks/Grade:
Course duration: From To Amount:
I hereby acknowledge that if this amount is deemed taxable in the future, I assume all liabilities that may arise
.
Signature of Applicant
FOR HUMAN RESOURCES USE ONLY
Date processed
:
Amount approved:
Approved by:
(Please attach original receipt)
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