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Request form Sampling Arrangement for Employees Kindly reimburse me the following amount, as per table given below,

which are duly supported by the attached Original cash memos / invoices, evidencing purchase: Month Serial No. :

Feb 13
Invoice No. Invoice Date Category Hotels - Stay Pack Others Foods

Year :

2012-13
Store Type Hotel Amount (`)

TIN NO; 29170588757 (JP Show room,Mysore) TIN NO: 29380350943 (MORE SHOP,Mysore)

23/02/12

1138.14

F&B Holiday Hotel

23/02/13

Outside / Others

423.25

23/02/13

- Biscuits
- Staples - Confectionery - Ready to Eat

CH NO; 1100037922 (MORE SHOP,Mysore)) NO: 11647003320 Csh;276986. TIN LST: 29970136297 (Brand factory,Mysore) INV NO: 12032878 (Travel house)

- Snacks
Personal Care

2657.00

23/02/13

LRBD - WLS

WLS Store

- JP
4
- Others Matches Agarbatti GGSB - Cards - Stationery Travel House - Tour Package

JP Store
7075.00

- Car Hire Local


- Car Hire Outstation Choupal Fresh Horti items Choupal Fresh Choupal Sagar

3016.9

Total

14310.29

I declare that I have read, understood and agree to the terms and conditions of this facility and am requesting the reimbursement accordingly. Place: Mysore. Signature: Name: Department : Technical.... Date: .. 23/02/13. For Office Use only Reimbursement eligibility for current financial year: (Based on date of joining) Request received on: Request processed on: Amount reimbursed till date Amount reimbursed now: Balance eligibility: Claims processed by : Name : ` ... .. ... ` ... ` ... ` ...

PRAVEENKUMAR KITTUR

Employee No.: 105495 Level / Grade:

G1/level 6

Signature:

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