Fillable Campus Assemblies Reimbursement Request (Cornell University)

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Campus Assemblies Reimbursement Request (Cornell University)

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109 Day Hall
Ithaca, NY 14853
p. 607.255.3715
f. 607.255.2182
e. assembly@cornell.edu
w. http://assembly.cornell.edu/
Campus Assemblies Reimbursement Request
This is a fillable PDF. Complete entries before printing on each use. For a list of subaccounts applicable to your
assembly see: http://assembly.cornell.edu/Main/PaymentForms. Attach receipts in the order they are listed below.
Section 1 – Organization completes this section and submits to address provided above
Assembly
Date Vendor Category/Subaccount Receipt
Total
Amount to
Reimburse
$ $
$ $
$ $
$ $
$ $
Business purpose TOTAL
$
Reimburse an Individual Reimburse University Department(s)
Payee Name
Payee Phone
Payee Email
Mailing Address
Account SubAccount Object Subobject
$
$
$
$
$
Last date to receive mail at address
We, the undersigned, submit the attached original receipts for expenditures and certify that they: comply with the budget
allotment granted to our organization by the University, are on behalf of the organization that we represent, are accurately
presented, and have not been submitted previously to the University or any other organization for reimbursement.
Recipient (if individual) Netid Signature
Financial Officer Netid Signature
Section 2 – University completes this section – ALLOW THREE BUSINESS WEEKS FOR PROCESSING
If the accounting distribution is included in an attached sheet, write “ATTACHED”.
Account-Subaccount Requester
Rev. 9/12/2012
G943702 - Student
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Campus Assemblies Reimbursement Request (Cornell University)

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Completed 15 November 2021

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