Health Professionals Student Association (HPSA) Reimbursement Request Form

Full name of person being reimbursed

Email of person being reimbursed

Name of group or event

Location of student group

HersheyUniversity Park

Adviser full name

Date of event

Brief topic of lecture/event

Where was the event held (city, state)

Purpose of event or purchase

Approximate number in attendance

Reimbursement amount

Please select the Student Account to be reimbursed

General Fund AccountGift Fund AccountBoth General and Gift Fund Account

Please indicate the dollar amount to be charged to the General Fund Account

Please indicate the dollar amount to be charged to the Gift Fund Account

Upload a copy of the itemized receipt for reimbursement (.jpg, .jpeg or .pdf files only)

Was this cost paid for with a credit card?

YesNo

Upload a copy of the credit card receipt for reimbursement (.jpg, .jpeg or .pdf files only)

Is this your first time submitting for reimbursement?

YesNo

Required Non-Employee Information Form

Note: All students seeking reimbursement must submit a copy of the University Non-Employee Information Form, found here, the first time they submit for reimbursement. Please download open that form, then save and complete it before uploading below. You will only do this the first time you submit for reimbursement.

Upload a completed version of the University Non-Employee Information Form (.jpg, .jpeg or .pdf files only)

Tax: Penn State College of Medicine cannot refund any state taxes charged during your purchase. If your reimbursement receipts have a tax amount listed, this will be deducted from your total refund amount.

Amazon Purchases: Penn State University prohibits reimbursement of Amazon purchases using personal credit cards. If you request reimbursement for items you purchased on Amazon, your request will be denied.

Upload an attendance list for your event/activity (.jpg, .jpeg or .pdf files only)

Contact Information