Student Organizaon Disbursement Request Form
*Please allow at least 15 business days from the me the fully completed and approved request form is
received in the Campus Life Oce to receive payment or Purchase Order number. *
Organization Name: _________________________________________________________________________________________
Account Number to be charged: 12-52- _______________________
Total Amount to be paid: $ ________________________
What is/are the reason(s) for the purchase(s):
________________________________________________________________
Event Date: _________________________________
Number of Attendees: __________ Students _________ Faculty _________ Staff _________Other
Type of Payment (Check One):
Reimbursement to Student, Faculty or Staff Member*
*Note: Faculty and Staff should complete Employee Reimbursement Form along with this form to be submitted to Campus Life
P-Card purchases made by__________________________________ from The ___________________________ Department on account
number _____________________________________ needs to be billed to student organization listed above
Payment/Purchase Order Request (College will send check directly to individual/company* May Require Additional Forms)
Transfer to another organization or campus department account: ___________________________________________________________
Payment Made Out To: ______________________________________________________________________Student I.D. #___________________
Address/Contact Information: _________________________________________________________________________________________________
Payment Approved By (Print Name, Sign Name, Date):
_________________________________________ Date: _______________
____________________________________ Date: ______________
_____ Treasurer: _____________________________________________
President (if over $50): _________________________________________
Advisor (if over $100): __________________________________________ ______________________________________ Date: ______________
Please note the amount by the appropriate account line:
Campus Council Expense58040 $__________________
Self Generated Account—58030 $__________________
Council Transfer Out—81002 $__________________
Self Generated Transfer Out $__________________
Campus Life Oce Use ONLY:
Received: ________________ Processed (if dierent than received): _________________
Requision ________________________ Entered _______________________ by __________________
PO # ______________________Date __________________ Received in Datatel ____________________
Notes:
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
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