Payroll PA03
EYE EXAM REIMBURSEMENT FORM
Applicable to UNIFOR 2458 Full-Time Group ONLY
For the refund of eye exam costs once each calendar year, to those UNIFOR 2458 Full-Time
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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