CLUB MANAGER PAYMENT OR REMBURSMENT REQUEST
To be filled out and submited by the club manager only.
Club Managers Name
*
First Name
Last Name
Email
*
example@example.com
Choose 4-H Club
*
Please Select
Bremond 4-H
Bows & Bullets 4-H
Calvert 4-H
Elliott 4-H
Franklin 4-H
Mumford 4-H
Wheelock 4-H
Type of Request
*
Please Select
Rembursment
Payment
Type of Expense
*
Please Select
Fundraiser
Community Service
Meeting Exp (meal, etc)
Donation
Other (explain below)
Description of items purchased / to be purchased
*
Purchased from
*
Amount of payment or rembursment requested
*
Payable to:
*
Delivery of payment
*
Mail Check to below address
Pick up Check at Extension Office
Pay online
Address if mailing check
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Upload a copy of Receipt or Invoice
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