Arizona Association for Marriage and Family Therapy

                 Request for Reimbursement Form

                            Submit to:

                       AzAMFT TREASURER
                         Karen Gage
                 4747 E. Elliot Road, #29-597
                    Phoenix, AZ  85044-1629

DATE: _______________

CHECK TO BE WRITTEN TO: ________________________________________

ADDRESS:                ________________________________________

                        ________________________________________

CHECK TOTAL AMOUNT: __________________  (PLEASE ADD UP RECEIPTS)

COMMITTEE or ACTIVITY: _________________________________________

CHECK CATEGORY, INDICATE AMOUNT, AND ATTACH RECEIPTS:

□  Printing and Copying  $ ________________
□  Postage               $ ________________
□  Telephone             $ ________________
□  Supplies              $ ________________
□  Meals                 $ ________________
□  Meeting Rooms         $ ________________
□  Other (specify)       $ ________________   ( _______________ )

OTHER INFORMATION: ______________________________________________

_________________________________________________________________

_________________________________________________________________

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(AzAMFT Treasurer Use)

CHECK NO: _______  DATE PAID: __________  AMOUNT PAID: __________