Picnix14 Reimbursement Form
                     Care of Linux Users' Group of Davis

               Please return with receipt(s) to the treasurer:

                         Linux Users' Group of Davis
                         Attn: Picnix14 Reimbursement
                         1105 Kennedy Place #1
                         Davis, CA 95616


NB: 1) Neither receipts without form, nor form without receipts 
       shall be accepted.
    2) There is a 60-day age limit on reimbursed receipts.


Your Name:            ____________________________________________________

Mailing address:      ____________________________________________________

Date:                 ____________________________________________________


Receipt # |  Amount  |  Description of items bought
__________|__________|______________________________________________________
          |          |                      
   1      | $        |                      
          |          |                      
   2      | $        |                      
          |          |                      
   3      | $        |                      
          |          |                      
   4      | $        |                      
          |          |                      
   5      | $        |                      
          |          |                      
   6      | $        |                      
          |          |                      
   7      | $        |                      
          |          |                      
   8      | $        |                      
          |          |                      
   9      | $        |                      
          |          |                      
   10     | $        |                      
          |          |                      
__________|__________|______________________________________________________ 


Total:      $_______   Number of receipts: ________


Additional information, if needed: