THE EVERGREEN STATE COLLEGE
2700 EVERGREEN PARKWAY NW
OLYMPIA, WA 98505
STREET OR BOX NUM
CITY STATE ZIP
BANNER ID DATE
YES NO
DATE UNIT UNIT PRICE
DATE
FUND ORG ACCT
ACCOUNTING APPROVAL DATE
REVISED 11/30/05
0.00
0.00
0.00
0.00
AMOUNT
TOTAL
0.00
OPTIONAL ACTV
VENDOR OR CLAIMANT (Warrant is to be payable to)
AGENCY NAME AND ADDRESS
SIGNATURE
FED ID/ SOC SEC
The Evergreen State College
FORM A-19
INVOICE VOUCHER
PRINT NAME
Vendor's Certificate. Under penalties of perjury, I certify that the items and
totals listed herein are proper charges for material, merchandise or services
furnished to the State of Washington, and that all goods furnished and/or services
rendered have been provided without discrimination because of age, sex, marital
status, race, creed, color, national origin, handicap, religion, or veteran status.
INSTRUCTIONS TO VENDOR OR CLAIMANT: Submit this form to claim
payment for materials, merchandise or services. Show complete detail for each
item and attach receipts.
INVOICE VOUCHER DATE
PREPARED BY
PRINT NAME
DATE
11/13/2012
ORGANIZATION APPROVAL SIGNATURE
BANNER INV. NO.
0.00
TOTAL
INDEX
AMOUNT
Is the payee or the beneficiary of the payment a U.S. citizen or permanent resident alien?
0.00
0.00
0.00
0.00
DESCRIPTION QUANTITY
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