C:\DOCUMENTS AND SETTINGS\FINANCE\DESKTOP\FORMS_NEW LOGO\EYE EXAM REIMBURSEMENT FORM - CAW 2458 FULL TIME - 2012.DOC
FINANCE DEPARTMENT
For the refund of eye exam costs once each calendar year, to those CAW employees who spend the
majority of their time operating VDT’s.
Last Name: _____________________________ First Name: _____________________________
Middle Name: __________________________ Employee I.D.: __________________________
Faculty/Department/Business Unit: _____________________________________________________
Amount Refunded: _____________________
DEPARTMENTAL AUTHORIZATION:
______________________________________ ______________________________________
EYE EXAM REIMBURSEMENT FORM
Applicable to UNIFOR 2458 Full Time Group ONLY
Submit Form To: Payroll Department. Any inquiries should be directed to this department at (519)
253-3000 ext. 2135
Revision Date: July 25, 2017 f
This reimbursement will be charged to the same business unit as your payroll and to
object account .8295.14
Name (please print)
Signature
PLEASE ATTACH ORIGINAL RECEIPT ONLY FOR REIMBURSEMENT AND FORWARD TO
PAYROLL
click to sign
signature
click to edit
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