Payment Request Form
Pembroke Minor Hockey
Final Approval Status
Name
*
First Name
Last Name
Email
*
example@example.com
Date
*
-
Month
-
Day
Year
Date
Division Request
*
Please Select
U7
U9
U11
U13
U15
U18
REP
Executive Request
Regular Expense Type
Please Select
Payment for House Team Tournament
Payment for Rep Team Tournament
Required Course Payment HEO
House League Tournament Expense
Executive Expense Request
Please Select
SilverStick Competitive Payment
Referee Payment
Ice Rental Payment
Professional Fees Payment
HEO Insurance Payment
Insurance Payment
Registration Expenses
HEO District Fee
UOVMHL Fees
Jersey Expense
Goalie Equipment
Other Equipment
Office / Committee Expense
Adverting / Donations / Promotions
Development Clinic Expense
QB Account
QB Account Number Description
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Please Select Team
*
Please Select
U7 - Team 1
U7 - Team 2
U7 - Team 3
U7 - Team 4
U7 - Team 5
U9 - Tier 2
U9 - Tier 3 Team 1
U9 - Tier 3 Team 2
U9 - Tier 4 Team 1
U9 - Tier 4 Team 2
U11B - Team 1
U11B - Team 2
U11C - Team
U13B - Team 1
U13B - Team 2
U13C - Team 1
U13C - Team 2
U15B Team
U15C Team
U18 Team 1
U18 Team 2
U18 Team 2
U11 Rep
U13 Rep
U15 Rep
U18 Rep
Name of Tournament
*
Start Date of Tournament
*
-
Month
-
Day
Year
Date
End Date of Tournament
*
-
Month
-
Day
Year
Date
When Must Payment be Made By?
-
Month
-
Day
Year
Date
Have you recived funds prior to this tournament from PMHA?
YES
NO
How much of your budget have you already used?
Have you updated your Sportheadz Calender on PMHA Website to indicate your tournament dates?
*
Yes
No
Any Special intructions regarding payment (IE - Message in the memo - Team Name Coach etc)
All Tournament information is correct?
Yes
No
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Which Division(s) where purchases made for
*
U7
U9
U11
U13
U15
U18
Silver Stick
Other
What was purchased?
*
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Please provide Details of Expense - Items purchased - courses taken - reason for payment to be made
*
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Please upload receipts / invoices for payment. This is mandatory in order to receive payment
*
Browse Files
Drag and drop files here
Choose a file
Cancel
of
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Which Vendor Requires Payment
Please Select
City of Pembroke
Westhmeath Township
Pembroke Referees
Musktrat Referees
Chad Brand
Leading Edge Athletics
Gordie Goldberg
Name of Person requiring Payment
Amount of Funds requested
*
Prefered Method of Payment
*
Physical Cheque (Minimum 7 Day Payment)
E-Transfer (Preferred method. Payment within 7 Days)
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Is the Payee on File Already?
Yes
No
Email Address for e-transfer payment
example@example.com
Cheque Made out to?
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Submit
Should be Empty: