RG Bar Services

Service Above the Bar

PHSMB

PHSMB – Request For Reimbursement

Please fill out all of the following fields and attach a copy of the receipt as an image file smaller than 7Mb.

Make sure to use the legal name and address as you would like it to appear on the reimbursement check.

Thank you greatly,
Roy Givon
PHSMB – Treasurer
858.395.3043

    First Name:

    Last Name:

    Mailing Address:

    City:

    State:

    Zip code:

    Phone number:

    Email Address:

    Amount requested:

    Reason or event:

    Please upload an image of the receipt (gif, png, jpg, or jpeg, with 7Mb limit):

    Upload image of second receipt (gif, png, jpg, or jpeg, with 7Mb limit):

    Upload image of third receipt (gif, png, jpg, or jpeg, with 7Mb limit):

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