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Act Missouri

Act Missouri

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Taking ACTion to Build a Healthy Missouri
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Home | Consultant Reimbursement Request Form – Field Form

Consultant Reimbursement Request Form – Field Form

Consultant Reimbursement Request Form -Field Form

  • Social Security Number Submission

    For security reasons we request you call or FAX us your social security number. ACT Missouri 428 E. Capitol, 2nd Floor Phone: 573/635-6669 FAX: 573/635-7257 aozenberger@actmissouri.org
  • Services Rendered

  • Pre-Approved Expenses as Identified in Contract

  • Receipts and Invoices

    All receipts and invoices must be attached for all reimbursable expenses.
  • Drop files here or
    Accepted file types: tiff, rtf, bmp, jpg, gif, jpeg, png, wav, mp3, txt, doc, docx, zip, pdf, tif, gz, tar.
    Please upload all receipts and invoices for reimbursable expenses.
  • Evaluation and Numbers Served

  • Drop files here or
    Accepted file types: tiff, rtf, bmp, jpg, gif, jpeg, png, wav, mp3, txt, doc, docx, zip, pdf, tif, gz, tar.
    Please upload your evaluation and your numbers served.
  • For ACT Missouri Use Only

  • Approved by: _____________________  
  • Approved dates: _____________________  
  • Fees: $_____________________  
  • Expenses: $_____________________  
  • Total: $_____________________  

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Info For Our

  • Prevention Resource Centers
  • Caring Adults
  • Youth
  • Educators

ACT Missouri Blog

Dec 06

Prevention Happened Here!

Dec 03

National Drug Take Back Totals

May 26

Prevention Wins Were Lean in 2019

Contact Us

428 E. Capitol, 2nd Floor
Jefferson City, MO 65101
phone: 573-635-6669
toll-free: 877-669-2280
fax: 573-635-7257
email: info@actmissouri.org

Prevention Resource Center Locator

Contact your local Prevention Resource Center to find out more about what’s going on in your community and how you can make a difference!
Get a map or see list of locations

Partners

  • Students Against Destructive Decisions (SADD)
  • Missouri Youth/Adult Alliance
  • Partnership for Drug-Free Kids

Important Info

  • About ACT Missouri
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