Please staple this corner

CHECK REQUEST
Check and highlight if pickup required Check if you have included a remit copy which must be sent with the check

TO:

FROM:
Department Name

Please prepare a check in payment to the below-named Vendor for the purchase of goods or services which DO NOT require a purchase order or contract under the terms of the Alachua County Purchasing Manual.

Explanation for payment (public purpose, P O exempt, etc.):

Attach any backup information necessary to explain payment request.

VENDOR #: CONTACT PERSON: VENDOR NAME: ADDRESS:

PHONE #:

RESPOSNSIBILITY COST CODE

FULL ACCOUNT #
ITEM # INVOICE #
15 digits

FUND #
3 digits

DEPT
4 digits

ACCOUNT #
7 digits

PROJECT
6 digits max

1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11.

TOTAL
I hereby certify that the Goods/Services have been received, and/or payment is authorized.

Primary Signature

Secondary Signature

ame

AMOUNT

$0.00

Date

Date