GCSU FOUNDATION PAYMENT REQUEST FORM

ACCOUNT NAME & NUMBER:

INVOICE NUMBER:

INVOICE DATE:

INVOICE DUE DATE:

FOR: (Attach receipts for reimbursements of items purchased, or explanation when services are rendered.)

AMOUNT OF THIS PAYMENT:

$

CHECK PAYABLE TO:

ADDRESS:

SOCIAL SECURITY/TAX ID NUMBER: (if applicable)

IF CHECK IS TO BE SENT TO

PERSON OTHER THAN PAYEE,

GIVE NAME AND ADDRESS:

PERSON REQUESTING PAYMENT:

(Signature and Date)

A P P R O V A L S:

Signature

Date

DIVISION/DEPARTMENT HEAD

FOUNDATION:

Signature

Date

TREASURER:

(if required)

Signature

Date