CUMC Payment / Reimbursement Form

Date:___________________

Pay to: __________________________________________________________________________

Item Purchased / Reimbursement:____________________________________________________

Account to Charge

$ Amount

Approval (Signature of Committee Chairperson):______________________________________

For Financial Administrator Use: Check #:_______________ Date: _____________________

CUMC Payment / Reimbursement Form

Date:___________________

Pay to: __________________________________________________________________________

Item Purchased / Reimbursement:____________________________________________________

Account to Charge

$ Amount

Approval (Signature of Committee Chairperson):______________________________________

For Financial Administrator Use: Check #:_______________ Date: _____________________