Requesting Department:  ______________________________   Date:  ___________________

Description/Purpose of check:  ___________________________________________________
Account(s) to be charged (required):                              Amount:

                    ______________________________             _______________
                    ______________________________             _______________
 
                    Total amount of check:                               _______________

Make check payable to (vendor's name):      ___________________________________

Payee/Vendor's Federal Taxpayer ID: ______________________
or Vendor ID:   ______________________
or Social Security No:  ______________________

Payment Address:      ___________________________________
                                 __________________________
                                 __________________________
Disposition:
                   _______   Mail check to payment address above
                   _______   Hold check   -   Call _____________________ at ext. ____________

Comments:   _________________________________________________________________
                       _________________________________________________________________

**Please note that all pay requests must designate the account number to be charged (including object code) and an authorized signature.  Paperwork received without these items will be returned to the requesting department.
 

Approved by:   ____________________________________________
                            (Department Head or Authorized Signature)

PLEASE ATTACH SUPPORTING DOCUMENTATION