Check Request Form

Name*

First

Last

Department*

Date*

Email*

Check Payable To: *

Amount of Check: *

Address*

Street Address Street Address Line 2 City State / Province / Region Postal / Zip Code Country

Purpose: *

Digital Signature of Requester: (type first and last name)*

**Note: CHECK REQUESTS WILL NOT BR PROCESSED WITHOUT DOCUMENTATION (I.E. RECEIPT, INVOICE, ETC). Prior approval must be obtained on all purchases. Failure to obtain approval may result in purchaser having to incur the expenses. Purchaser will not be reimbursed for sales taxes paid. (Type "Yes" to confirm you have acknowledge this statement) *

Supervisor of Requesting Staff Member

Date

Chief Administrative Officer

Date

Chief Financial Officer

Date

BELOW IS ACCOUNTING USE ONLY

Date Recieved

Funding Source

Comments

Processed By Initials:

Date

Email

Phone

Fax

Address