DATE: _____________________________

 

APPROVED FOR PAYMENT BY: (MUST HAVE SIGNATURE OF COMMITTEE CHAIR OR AUTHORIZED BOARD MEMBER)

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COMMITTEE BUDGET TO BE CHARGED: _________________________

 

PURCHASED FOR WHAT PURPOSE: ______________________________

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AMOUNT DUE (TOTAL OF ALL ATTACHED RECEIPTS):  $___________

 

PAY TO ORDER OF: ______________________________________________

 

ADDRESS: ______________________________________________________

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