COMMITTEE PAYMENT REQUEST
Please Check One:

  
[   ]  CHECK REQUEST         [   ]  CREDIT CARD AUTHORIZATION

Requestor information:

Date:______________________________

Amount:___________________________

Name:________________________________________________

Lot #:________________________

reason for purchase:

_____________________________________________________

_____________________________________________________

_____________________________________________________

chairperson/approval information:

Committee:___________________________________________

Date:____________________________

Amount:__________________________

Acct no._________________________________  $___________

acct no._________________________________  $___________

acct no._________________________________  $___________

approved by:__________________________________________

Lot #:_____________________

signature:____________________________________________

*** attach receipt/billing ***
use additional sheets as needed

Committee Chair or Co-Chair MUST pre-approve
any expenditure prior to the use of the corporate credit card.