Dairy Workers Association, Inc.

Driver License Reimbursement

DWA drivers may use this form to request reimbursement for an eligible driver license expense. Submission does not guarantee approval or payment.

Protect your personal information.

This request is emailed only to the DWA President. Upload only the receipt or document needed to support the request. Do not include a Social Security number, bank information, or unrelated personal records.

Driver information

First name

Last name

Employee identification number

Email address

Phone number

Dispatch location

Reimbursement request

Date the expense was paid

Reimbursement amount requested

Proof of payment How will you provide the receipt?

Choose how you will provide proof of payment.

Certification and signature I certify that I am a current DWA driver and that this request and supporting proof are accurate and complete. I understand that submission does not guarantee reimbursement.

Type your full legal name as your electronic signature

Request date

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