Reimbursement form — Sports or cultural activities

A maximum delay of three (3) months following the payment of an activity or a new membership is granted when presenting a request for a financial reimbursement to the Municipality of Bolton-Est. The date stated on your receipt is the reference used for the applicable delay of three (3) months. Following this delay, your financial request will be refused.

Cheque labeled to

Given name•

Family name•

Email•

Telephone•

Address•

Postal code•

Participant's information

Participant 1

Given name•

Family name•

Name of activity•

Amount paid ($)•

Total reimbursement claimed ($)•

Documents required to join with this form

Select the documents you are providing•

Proof of residency

Proof of payment of the activity

Attach documents•

Drop files here or click to upload them.

Consent and signature

I declare that all information is accurate and true to the best of my knowledge. •

I consent to the collection of my personal information entered by the Municipality of Bolton-Est for the purpose of this request. •

Signature •

Date