Chapter and Club
Payment or Reimbursement Form
Fresno State Alumni Association | www.fresnostatealumni.com | Phone: 559.278.ALUM | Fax: 559.278.6790
____________________________________________________________
Instructions:
1. Complete one form for each payment or reimbursement you are requesting.
2. Requests must be completed and turned into the FSAA no later than 15 days of the date of the
invoice/purchase to allow for an accurate monthly budget report.
3. Original invoices and/or receipts must be provided with the completed form (can be mailed or delivered).
4. The individual receiving reimbursement may prepare the form and may sign as the “Preparer”, but they
may not be one of the individuals approving payment. An individual may not prepare and sign their own
reimbursement form.
5. For any reimbursement or payment over $250, two “Approved signers” signatures are required.
6. “Approved” signers must be those officers listed as Authorized Signers on the chapter/clubs account.
Is this a:
[Payment to a person] Reimbursement for an expense already incurred.
[Payment to a vendor] Payment on an invoice.
[Payment to a campus department/program/unit] Payment/transfer of funds to an on-campus entity.
PAYMENT INFORMATION
Vendor/Person name: ______________________________________________________________________
Mailing address: ______________________________________________________________________
City: _______________________________ State: ________ Zip: ____________
Amount: $______________
If an invoice: Invoice #: ______________________ Date: _______________
HOW WOULD YOU LIKE TO RECEIVE PAYMENT?
U.S. mail Pick up at the Fresno State Alumni Association office
Person picking up check: ________________________________________________
Cell phone (required): ________________________________________________
EXPLANATION OF COST
Event: ______________________________________________________________________
Location: ___________________________________________ Date: _________________
ACCOUNT SIGNER AUTHORIZATION
Prepared by
(print name): ___________________________________________ Date: __________________
Approved signer #1
Print name: ___________________________________________________________
Signature: ________________________________ Date: __________________
Approved signer #2
Print name: ___________________________________________________________
Signature: ________________________________ Date: __________________
