CHECK REQUEST

      Date:                                            Requested by:                                       

      Amount $                                      Department:                                       

      Required When:                              Mail Check:  Yes þ    No þ   


      Payable To:                                                                                           

      Address:                                                                                               

      City:                                             State:                    Zip:                      

      Contact:                                        Phone:(       )                                     


      Reason for Check:                                                                                  

                                                                                                                

                                                                                                                
      

      Approved by:                                  Date:                                               



                              Accounting Use Only


                                       
      Check No.                                               Account Codes           Amounts

      Date:                         

      Issued by: