SPEF - Disbursement Request

Grant Information

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

Computers and or software purchase or educational technology upgrades Study area desk, chairs, and or other approved furnishings Books, libraries, and academic files Study area renovations
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 Grades Essay Submission New Member Curriculum Completion
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 Name Last Name
Recipient Phone Number *

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

Yes No
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 Conference Tony Siress Leadership Summit
Reimbursement for: *

Travel Registration
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 Name Last Name
Title or Relationship to the Chapter? *
Phone Number *

Area Code Phone Number
Your Email *
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
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General Information