All checks may take up-to 20 business days to process
Request for Payment Form
THIS FORM TO BE PROCESSED ONLY IN THE OFFICE OF STUDENT INVOLVEMENT & ORIENTATION
All appropriate fields must be complete to insure prompt payment.
Date:
Club Name: Index Code:
Amount to be paid: $ Type of Payment: ( ) Cash Advance
( ) Cash Box
( ) Donation
( ) Honorarium – attach W‐9 form and I.C.P.R.
( ) Pay Vendor – attach invoice
( ) Reimbursement – attach receipts
( ) Transfer funds to another campus account
( ) Travel (fill travel section out)
Pay to: Phone #: Email:
Bengal Card # for student / Social Security # for payment to non‐students
Address:
Explanation of Expenditure or Destination and Purpose of travel (please include quantities, prices, dates, etc.):
Travel:
Are you claiming gas? If yes, Car License #: Number of Travelers:
Names of travelers other than yourself?
Departure Date: Return Date: If Advance, Check Need by Date:
Two Authorized Signatures: Print Name: Phone #:
***If you have any questions, please call 282‐3451***
Up to $200 can be taken out on a cash advance. Original detailed receipts required. Receipts must be turned in 2 business
days after the transaction occurs.
Reimbursements over $200 will have a check mailed. Checks take 20 business days to process and mail.
Club members/advisors understand that they must disclose all family relationships between themselves/club
advisors/officers and all payees on all financial documents prior to commitment or disbursement of any funds.
