Employee Reimbursement Request
Please do not use this form for travel reimbursements.
State Org Name:
Employee Name:
State Org. Number:
Employee Address:
wvOASIS GAX ID:
wvOASIS vendor ID:
Quantity
Description of Items
Unit Price
Total
Purpose of expenditure:
Employee signature / date
Supervisor signature / date
WVSAO ER-1 Last revised 7/11/14
Fairmont State University
0484
Org/Unit:
Object:
Fund
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