Check Request Form

Name*

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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: *

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**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) *

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

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