Rotary of Central Chester County Check Request Form

PO Box 239, Lionville PA 19353-0239

Requested By:_____________________________________

Date: ___________________

Name & Address of Payee:

__________________________________________________

__________________________________________________

__________________________________________________

Expense Listing/Description        Operating Account Charged        Amount Charged

_________________________    ________________________      _________________

_________________________    ________________________       _________________

_________________________    ________________________       _________________

_________________________    ________________________       _________________

_________________________    ________________________       _________________

_________________________    ________________________       _________________

                                                                           Total Request: $ ____________________

NOTES:

Please complete this form and submit to Club Treasurer to obtain reimbursement or to have the Club send a check directly to a supplier.

It is important that you indicate the Project or Club Expense Account to be charged for each disbursement.