Olympic Educational Service District 114
105 National Avenue North, Bremerton, Washington 98312
(360) 478-6887  1-800-201-1300  FAX (360) 405-5808

Olympic ESD 114 Early Learning

NON-TRAVEL REIMBURSEMENT FORM

Date: Click or tap to enter a date.

Name: Click or tap here to enter text.

Full Mailing Address: Click or tap here to enter text.

Note: All purchases of goods and services require prior approval. Staff who obligate Olympic ESD 114 without proper authorization may be held responsible for payment, such as obligations.

Please attach all receipts to your email when submitting this form electronically (or in-person).

DATE	PAID TO	PURPOSE OF PURCHASE	AMOUNT
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I hereby certify under penalty of perjury that this is a true and correct claim for necessary, pre-approved expenses incurred by me and that no payment has been received by me on account hereof.

Claimant Signature: Click or tap here to enter text.	Date: Click or tap to enter a date.

Supervisor Approval: Click or tap here to enter text.	Date: Click or tap to enter a date.

Director Approval: Click or tap here to enter text.	Date: Click or tap to enter a date.