DATE: ____________________

PAYABLE TO:

NAME: _____________________________________________________

ADDRESS: _________________________________________________

         __________________________________________________

PHONE: ____________________________________________________


EXPLANATION OF PURCHASE: _________________________________

__________________________________________________________

__________________________________________________________

__________________________________________________________

AMOUNT OF REIMBURSEMENT: ________________________________
Smithtown Stitchers Reimbursement Form
OFFICE USE:

DATE: _________________

CHECK #: ______________

TREASURER SIGNATURE: ______________________________________
** IF YOU WOULD LIKE YOUR REIMBURSEMENT CHECK MAILED TO YOU,
PLEASE PROVIDE A SELF ADDRESSED, STAMPED ENVELOPE.  THANK YOU.