SPEF - Disbursement Request

Grant Information

Disbursement Request
Grant To:*
Legal Entity Name
To Be Used For:*

Computers and or software purchase or educational technology upgradesStudy area desk, chairs, and or other approved furnishingsBooks, libraries, and academic filesStudy area renovationsOther
Description of Educational Impact Achieved by Funds*
Upload invoices, quotes, schematics, or other proof of desired improvements*

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Scholarship Information

Disbursement Request
Name of Scholarship*
Description of Criteria for Scholarship *
Why is this individual receiving the scholarship?*

GPA or GradesEssay SubmissionNew Member Curriculum CompletionOther
Upload Proof of GPA, Essay Submission, etc*

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Must Upload Student Identification Card*

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Scholarship Payable To:*
Name of Host Institution
Recipient Name*

First NameLast Name
Recipient Phone Number*
Recipient Email*
Name and address for check to be sent?*
Do you need certificates?*

YesNo
Where do certificates need to be sent?*
Please enter Email for digital certificates or Physical Address for printed certificates. NOTE: Printed certificates may take 4-6 weeks for distribution.

Educational Programming Information

Disbursement Request
NOTE: Must comply with US Tax Code and IRS Regulations
Type of Educational Programming*

Mid-Year Leadership ConferenceTony Siress Leadership SummitEngageConvocationOther
Reimbursement for:*

TravelRegistrationOther
Upload Receipt(s)*

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Upload Proof of Registration*

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Submission

Disbursement Request
The undersigned understands this is a request for disbursement only and does not constitute a commitment by or contract with the Foundation to disburse funds.

The undersigned agrees to obtain and provide to the Foundation any documentation and other information needed to verify use of any disbursed funds, as requested.

The undersigned agrees that any funds disbursed as a result of this request, but not used for the purposes set out in this request, must be returned to the Foundation.
Your Signature*

Clear
Your Name*

First NameLast Name
Title or Relationship to the Chapter?*
Phone Number*
Your Email*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
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General Information