IMPS: FORM FOR PERSONAL REIMBURSEMENTS

Note: This form can only be filled in by an IMPS Volunteer. If you are not an IMPS Volunteer and you have picked up a dog, please call the IMPS Hotline at 1-877-Minpin1, or contact an IMPS Regional Coordinator nearest to you.
 
 
DOG'S NAME:    IMPS TAG NUMBER:    
AMOUNT TO BE
REIMBURSED:

NOTE: copies of vet/shelter bills MUST accompany this.
VOLUNTEER's
NAME:
ADDRESS:
Email address:

PLEASE PRINT AND FAX A COPY OF THIS COMPLETED FORM, TOGETHER WITH COPIES OF VET/SHELTER BILLS TO:

Vince Giammusso - IMPS, Inc.
FAX: (856) 694-3338
Email: vinniegia@comcast.net

IF YOU PREFER TO SNAIL-MAIL THE FORM AND COPIES OF BILLS, PLEASE EMAIL VINCE (vinniegia@comcast.net) FOR A MAILING ADDRESS.

THIS FORM MUST BE SUBMITTED WITHIN 30 DAYS OF THE TREATMENT OR EXPENSE.