Date:
Vendor Name:
Address (Street):
Address (Town, State, Zip):
Payment Amount: Attach Supporting Documentation.
Account Number: Confirmed Availablity of Budget
Check Requests will be returned if Budgeted Funds are not available.
(Use "ACBL" Inquiry Screen in Datatel)
Membership
Subscription/Publication
Conference/Seminar Registration TRA Required
Hotel Costs TRA Required
Insurance (excluding Nurse Malpractice - Use "REQM" screen in Datatel)
Referee/Umpire
Security Criminal History Checks
Send supporting documentation with check to the vendor.
Note the following on the check stub:_____________________________________________________________
Hold check for pick-up by the Originator. Originator's phone extension: _______________
Other. Describe:______________________________________________________________________________
Originator's Name (Please Print) Phone Extension
Department Head
APPROVAL
CHECK REQUEST FORM
For instructions on the use of this form, please see policy #03.10.
CHECK REASON FOR USING THIS FORM.
If reason is not available, this form CANNOT be used.
SPECIAL INSTRUCTIONS
Check Requests will be returned if amount requested is not adequately supported.
Check Request - Eform - Rev. 6-2014
