WHITEHEAD INSTITUTE

CHECK REQUEST FORM (EXAMPLE)

       Do not complete shaded areas   
DATE: 04/08/02 TA Number (If applicable):  
Use this form to request payment for goods or services not processed with purchase order. Attach original receipts to this form
If invoice has space to write the accounting and other payment information, you do not need to complete this form. You may want to write directly on the invoice and submit the invoice for payment.
PAYEE INFORMATION
If payment is being made to an individual who is acting as an independent contractor, Social Security Number or Tax ID Number is required
Payee Name:  Lawson Training Group SS#/Tax ID#:  N/A
Payee Address (Please provide complete address)
122 Stuart St , Suite 33
San Antonio, TX 10403
DEPARTMENT/LAB CONTACT INFORMATION PAYMENT DISTRIBUTION
Name: Mary Jo
  Mail to Payee: (yes)___ (no)____ 
Phone Number: 8-4444
  Return to:_________________
FUNDING INFORMATION
If it is not appropriate to split all charges among the activities identified below, please submit backup identifying specific charges to specific activities.
ITEM
ACTIVITY Number/Description
ACCOUNT CATEGORY Number/Description
SHORT ITEM DESCRIPTION AMOUNT
1
01-0010-0101/Acctg & Grants
6025/ Registration Fees
Lawson Conference 995.00
         
 
gggggggggggggggggggggggggggg       
     TOTAL CHECK AMOUNT
$995.00
EXPLANATION OF PAYMENTS (Back up documentation is required)
ITEM
 DESCRIPTION 
1
 Lawson User conference, San Antonio Texas, from April 20th to the 26th 
   
 
   
REQUIRED SIGNATURES/APPROVALS
Payment Requested by (1)     Date:  
Dept./Lab Approval -Name and Signature (2)   Date:  
Grants/Business Office Approval (3)   Date:  
(1) If requested for personal reimbursement, this signature is for the individual requesting payment. This signature indicates that the information provided is correct, and proper receipts are included.
(2) Indicates that funds are available to cover the charges.
(3) Indicates that charges are coded to the appropriate activities/account categories
ACCOUNTING USE ONLY
DATE:_______________       ENTERED BY:__________   
VOUCHER #:___________       INVOICE #_____________   

Last Updated on 5/21/02
By User