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cell phone reimbursement request

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					         GREEN RIVER DISTRICT HEALTH DEPARTMENT
         CELL PHONE REIMBURSEMENT REQUEST FORM

This form must be submitted for supervisory approval before submitting to
Financial Office.

I request approval for reimbursement of my cell phone used during business hours.

EMPLOYEE INFORMATION:

___________________________________________
NAME

___________________________________________
ADDRESS

___________________________________________
CITY, STATE ZIP CODE

___________________________________________
PROGRAM

CELL PHONE ACCOUNT INFORMATION:

___________________________________________
NAME AS IT APPEARS ON BILL

___________________________________________
ADDRESS AS IT APPEARS ON BILL

___________________________________________
CITY, STATE ZIP CODE

__________________________________________
CELL PHONE NUMBER

Employees are responsible to assure all information contained herein is true and
accurate. The above cell phone is used for business purposes for GRDHD. Any
false statements or misrepresentations will result in repayment of funds to GRDHD.

___________________________________                ______________________________
Employee Signature            Date                 Supervisor Signature    Date


5/2/03

				
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