REQUEST FOR REIMBURSEMENT OR PAYMENT

TO: AAQG TREASURER DATE

NAME: ________________________________

BUDGET LINE ITEM______________________

DATE	DESCRIPTION OF GOODS/SERVICES	AMOUNT
	TOTAL REIMBURSEMENT REQUESTED:

CHECK PAYABLE TO:____________________________

MAIL TO: ______________________________________

______________________________________

(Fill in only if check is to be mailed)

APPROVAL BY PRESIDENT__________________________________ DATE___________

PAYMENT BY TREASURER__________________________________

CHECK NUMBER___________________ DATE____________