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(CO15) Volunteer Reimbursement Request Form

  1. Campbell County Public Safety Document Header
  2. Volunteer Reimbursement Request Form
  3. Volunteer Name
  4. Name and Address of Person Transported
  5. Household Member?
  6. Confirmation Statement*

    By checking the "I confirm" box, you indicate that any and all insurance has been collected and applied toward the cost(s) of this transport and the person transported resides at the address listed above.

  7. Electronic Signature Agreement*

    By checking the "I agree" box below, you agree and acknowledge that: 

    • 1) your submission will not be signed in the sense of a traditional paper document;
    • 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature; and 
    • 3) you may still be required to provide a traditional signature at a later date.
  8. Leave This Blank:

  9. This field is not part of the form submission.