PTL Receipt Form

Check which best describes you....*

Other: Please Describe

Name*

First Last

Email*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Function/Event/Item*

Amount Spent*

Date Payment Due

Explanation of Cost*

Please include details of purchase and any links to receipts. Scanned or saved receipts can be added below.

Receipt(s)

Drop files here or

Max. file size: 16 MB.

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