Requisition / Reimbursement / Advance Form
Fifteenth Street Quaker Meeting
Date
*
-
Month
-
Day
Year
Date
Submitted by:
*
First Name
Last Name
Check payable to:
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number:
Please enter a valid phone number.
Format: (000) 000-0000.
Committee:
*
Budget or fund:
*
Amount:
*
Purpose:
*
PLEASE ATTACH THE RECEIPT (for reimbursement) OR THE BILL (for direct payment to the provider of the goods or services, payee’s name and address must be on the bill).
*
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Committee clerk name:
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Committee clerk signature:
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