Operator Reimbursement Request Form

July 2025 to June 2026 Water System Operator Reimbursement Program
Operator Reimbursement Request Form

All fields marked with * are required and must be filled.
Who is requesting reimbursement?*

OperatorCity/Utility/Employer
Name of Operator*
Operator's Email*
Name of City/Utility/Employer*
Course Information

A copy of the certificate of completion and receipt for course fees must be submitted with this form.
Name of Course Sponsor*
Name of Course*
Date(s) of Course*
Course Fees Paid*
Travel and Lodging (if applicable)

Only in-state travel costs are eligible for reimbursement. Copies of receipts must be submitted with this form. The following are NOT reimbursable (this list is not comprehensive): per diem, rental cars, parking, taxi fare, gas, mileage, etc.
Dates of Travel
Explanation of Travel (including mode of travel, airline/flight information, hotel name, etc.)
Travel and Lodging Costs
Total Costs (course fees plus travel expenses)*
Attach Documents

Attach copies of course completion documents, course receipts, and travel receipts in the box below.
File Upload*

Cancelof
Have you attached all of the applicable documents?*

Copy of Course Completion CertificateCopy of Course Fee ReceiptCopies of All Travel Receipts (if applicable)
I hereby certify that the information provided on this form is true and complete to the best of my knowledge and belief. I further understand that I may not receive reimbursement if the funding source has been exhausted.*

Yes
Operator's Signature*

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July 2025 to June 2026 Water System Operator Reimbursement Program

Operator Reimbursement Request Form

Course Information

Travel and Lodging (if applicable)

Attach Documents