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FORM #2
PERSONAL, PROHIBITED & UNAUTHORIZED PURCHASES
EXPLANATION & REIMBURSEMENT
Cardholder:
Statement Closing Date:
Date of Transaction:
Vendor:
Dollar Amount:
Budget Code:
EXPLANATION:
*Forward check for reimbursement along with this form to Debbie Przybylowicz in
GW 311.
Check #
*Do not enclose in your PCard Envelope*
Cardholder Signature Date
Dean/Supervisor Signature Date
Print Form