July 2025 to June 2026 Water System Operator Reimbursement Program
System Reimbursement Request Form
All fields marked with * are required and must be filled.
Name of City/Utility/Employer
*
Name of Person Completing This Form
*
Email Address of Person Completing This Form
*
Course Information
Copies of the certificates of completion and receipts for course fees must be submitted with this form.
Name of Course Sponsor
*
Name of Course
*
Dates of Course
*
Expense Information
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.
Operator Expenses
*
Operator Name
Explanation of Expenses
Cost for this Operator
Operator 1
Operator 2
Operator 3
Operator 4
Operator 5
Operator 6
Operator 7
Total Actual Costs
Attach Documents
Attach copies of course completion documents, course receipts, and travel receipts in the box below.
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Have you attached all of the applicable documents?
*
Copies of Course Completion Certificates
Copies of Course Fee Receipts
Copies 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
Signature of Person Completing This Form
*
Date
*
-
Month
-
Day
Year
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*
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