Student Organizaon 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 Oce 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 Expense—58040 $__________________
Self Generated Account—58030 $__________________
Council Transfer Out—81002 $__________________
Self Generated Transfer Out $__________________
Campus Life Oce Use ONLY:
Received: ________________ Processed (if dierent than received): _________________
Requision ________________________ Entered _______________________ by __________________
PO # ______________________Date __________________ Received in Datatel ____________________
Notes:
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
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