Purchase/Reimbursement FormsEngineering Business Center-North

Purchase/Reimbursement Forms

Engineering Business Center-North

Please see the Business Purpose Guide for examples of appropriate business purposes.

Please see the Reasonable Expense Guide for more detailed information about appropriate and reasonable expenditures.

Please ensure that you submit the form before closing the tab or browser window, as the data entered cannot be saved for later access.

All fields marked with an * are required. If you are unable to submit the form, please ensure that all required fields have been completed.

File Upload:

To help reduce processing time, please submit all documents in PDF format. Each submission is limited to 10 files. If you have multiple PDFs, please consolidate them into a single file before uploading. Receipts should be clear and legible before being uploaded.

If your receipts are in a language other than English, providing English translations or descriptions of each expense can greatly assist reviewers in understanding the details, reducing the need for further clarification. If translations are not provided, other supporting documents, such as bank statements, may be required to verify the expenses.

For technical support or if you have any questions regarding the forms, please contact the Engineering Business Center-North Office at: engr-ebcn@arizona.edu

Date of Submission*

Select Department:

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Are you Submitting on Behalf of Someone?

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Enter Name of Faculty/Staff/Student*

Enter Your Name:*

Enter Your Employee ID

Select Form Type*

Expense Reimbursement

Travel Reimbursement

Pcard Purchase

Requisition/PO Request

Last 4 Digits of Pcard*

Is This Purchase Tax Exempt?

If your purchase is tax exempt, work with Vendor to remove sales Tax before submission. There could be refund of the Tax. Please contact your business office if you have any questions.

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Is this a Purchase or Refund?

Purchase

Refund

Receipt Amount $$

Select Expense Category(-ies):

Select

Was Alcohol Purchased?

Yes

No

Select Travel Expense Category(-ies)

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Other-Provide Details of Type of Expense

Vendor Name(s)

Enter Funding Account/Subaccount(s)*

Please List Funding Split if Multiple Accounts Will Be Used.

International Travel?

UA International Travel Website

Select or enter value

Registry ID Number*

Travel Authorization Number*

University Travel Authorization Access Tool(Concur)

Travel Dates:

UA Business Purpose- Benefit to the University(2-3 Sentences)*

Reference "Business Purpose Guide"

Conference Dates:

Are You Requesting Mileage?

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# of Miles (From/To)

Please Provide Address From/To OR Odometer Reading

Requesting Per Diem

Select

Were you Provided Meals?

Yes

No

Meals Provided- List Date and Meal(s) Provided:

Select Lodging:

Designated Hotel-(Includes Authorized Overflow Hotel)

Non-Designated Hotel

Justification for using Non-Designated Lodging

Shared Rooms?

Yes

No

List names of Individuals:

Will the Purchase be Above $50,000?*

Yes

No

Has the Significant Purchase Request Form Been Completed?*

Yes

No

Do not Proceed. Complete Form and Contact Your Business Office

You will need to submit form to be reviewed/approved prior to submitting your Purchase Order Request.

Significant Purchase Request Form

Shipping Address:

Will the Asset/Equipment location be the same as the shipping address?

Yes

No

Enter Asset location: (Ex. Building Name, Address, and Room/Lab Number)

Total Reimbursement $ Amount Requested*

File Upload-Each submission is limited to 10 files*

If you have multiple PDFs, please consolidate them into a single file before uploading.

“Supporting Documentation Requirements”

Itemized receipts for ALL expenses are required. Receipts must show the date of the expense, the total amount paid, a description of what was purchased, and a payment method. Lodging receipts should show breakdown of nightly rate and taxes/fees.

Drag and drop files here or

Additional Comments/Requests

Signature Required:

I HEREBY CERTIFY THAT ALL ITEMS OF EXPENSE INCLUDED IN THE ABOVE AMOUNT WERE NECESSARY IN DISCHARGING THE OFFICIAL BUSINESS OF THE STATE; THE DISTANCES HAVE BEEN ACTUALLY TRAVELED ON THE DATES SPECIFIED; NO PART OF THE ACCOUNT HAS BEEN PAID BY THE STATE OF ARIZONA AND NO CLAIM AGAINST THE STATE HAS BEEN MADE FOR ANY PART THEREOF, BUT THE FULL AMOUNT IS DUE AND UNPAID; AND I DECLARE, UNDER PENALTIES OF PERJURY THAT THIS CLAIM HAS BEEN EXAMINED BY ME AND TO THE BEST OF MY KNOWLEDGE AND BELIEF IS TRUE, CORRECT AND I ATTEST THAT I HAVE NOT BEEN PREVIOUSLY REIMBURSED FOR THESE EXPENSES NOR HAVE THEY BEEN PAID FOR BY THE UA PCARD. I HEREBY ASSIGN THE WITHIN STATE CLAIM TO THE UNIVERSITY OF ARIZONA AND AUTHORIZE THE ASSISTANT DIRECTOR FOR FINANCE TO ISSUE THIS REIMBURSEMENT ACCORDINGLY.

Signature Required:

I HEREBY CERTIFY THAT THIS REIMBURSEMENT REQUESTED IS FOR BONA FIDE UNIVERSITY OF ARIZONA BUSINESS PURPOSE AND HAS NOT BEEN PAID VIA THE UNIVERSITY PCARD NOR PREVIOUSLY REIMBURSED. ANY SERVICES PROVIDED OR EQUIPMENT PURCHASED SHALL REMAIN THE PROPERTY OF THE UNIVERSITY OF ARIZONA.

Enter your name (serves as your signature)

(Leave this field blank if submitting on behalf of another individual)

Requestor Email Address*

Send me a copy of my responses

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