Complete the form below to receive your reimbursement.

I request mileage reimbursement for attendance of Vidant Board meeting(s) on the date(s) listed below:

  • MM slash DD slash YYYY
  • MM slash DD slash YYYY
  • MM slash DD slash YYYY
  • MM slash DD slash YYYY
  • MM slash DD slash YYYY
  • MM slash DD slash YYYY
  • Reimbursement shall be at the rate of 58 cents per mile.
  • Please do not navigate away from this form before submitting as all data entered will be lost.