DATE: ________________________

EXPENSE ACCOUNT NAME: ____________________________________________

EXPENSE CODE NUMBER: ______________

DOLLAR AMOUNT: $_____________________

PAY TO THE ORDER OF: _______________________________________________

RECEIPT ATTACHED: YES__________NO__________

REQUESTER: __________________________________________________________

SIGNATURE: __________________________________________________________

CHECK#_______________ AMOUNT $_______________ DATE: _______________

APPROVED BY: ________________________________________________________

SIGNATURE: __________________________________________________________