Payroll PA02
EYE EXAM REIMBURSEMENT FORM
Applicable to Non-Union Administration Full Time ONLY
For the refund of eye exam costs once each 24 month period, to those Non Union Administration
employees who spend the majority of their time operating VDT’s.
Employee Information:
Last Name: _______________________________ First Name: _______________________________
Employee Number: ______________________Department: _______________________________
Amount Refunded: _________________________
This reimbursement will be charged to the same account as your payroll and to natural
account 81676.
Department Head Authorization:
_____________________________________ ______________________________
Signature Date
PLEASE ATTACH ORIGINAL RECEIPT ONLY FOR REIMBURSEMENT AND
FORWARD TO PAYROLL
Submit Form To: Payroll Department. Any inquiries should be directed to the Payroll department at
payroll@uwindsor.ca.
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