Reimbursement - Kick at Darkness

Your Name *

First

Last

Your Email *

Confirm Email

Your Phone *

Your Address (where a check could be sent) *

Address Line 1

Address Line 2

City

State

Zip Code

If You Have PayPal, What Email Do You Use?

Type of Expense (use separate forms for each type of receipts) *

Describe Expense (i.e. bubbles for Warrior Kit) ** Attach image of your receipt below** *

Who Approved Your Expense? *

Are You Seeking Reimbursement or Receipt of Donation? *

If You Do Not Attach a Clear Image of Your Receipt, Your Request Will Not Be Processed: *

Submission Is Not a Guarantee of Reimbursement | Your Request Will Be Submitted for Approval: *

Do You Have Any Notes We Should Know? (Including name to be on check):

Attach an Image of Your Receipts (.pdf, .jpg, .png) *

Attach an Image of Your Receipts/Items (.pdf, .jpg, .png)

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