QUALITY CAREER SERVICES INC. 2515 Wabash Ave., Suite LL1 St. Paul, MN 55114 Office Phone: 651-647-9322 FAX: 651-647-0423
Due to limited funding, reimbursement will be paid for ONE round trip per day.

Your Name: _______________________ Company laid off from: ________________

Address: __________________________________________________________

City/State/Zip Code: _________________________________________________

* MUST BE SUBMITTED MONTHLY OR PAYMENT MAY BE DENIED.
* MUST BE RECEIVED IN OUR OFFICE BY THE 15TH OF THE FOLLOWING MONTH OF THE CLAIM.
* IF YOUR NAME/ADDRESS/CITY IS NOT COMPLETED (ABOVE) AND/0R YOU DID NOT SIGN YOUR NAME AT THE BOTTOM OF THIS FORM YOUR PAYMENT WILL BE DELAYED.

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Signature (MUST BE SIGNED BY CLAIMANT) ________________________________