General Reimbursement

OHIO SWIMMING INC.
General Reimbursement Form
Name

First NameLast Name
Club Affiliation
Reimbursement Type:
LSC Position (select all that apply):

Other
Officials Background Reimbursement
Please select reimbursement:
Total amount to be reimbursed
Upload Scanned Copy of Receipts:
(Background screen receipt should have been emailed to you)
Upload Receipt #1

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General Reimbursement
Total amount to be reimbursed
Please select reimbursement type:

Other
Which budget category is this reimbursement from?

Other
Upload Scanned Copy of Receipts:
(You may upload all receipts bundled in a single file or by category)
Receipt #1
Receipt #2
Receipt #3
Receipt #4
Upload Receipt #1

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Upload Receipt #2

Cancelof
Upload Receipt #3

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Upload Receipt #4

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If you prefer to mail in your receipts, please send them to the Ohio Swimming Office within 24 hours of submission of this request form. Please either include a printout of your confirmation of submission or write your name on your receipts and send to:
5020 B College Corner Pike Oxford, OH 45056
REIMBURSEMENT INFORMATION:
Make check payable to
Phone Number
Please enter a valid phone numberFormat: (000) 000-0000.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email
example@example.com
Should be Empty:

Officials Background Reimbursement