American Society for Clinical Laboratory Science - PA

Requisition for Funds                                                                                                      Treasurer Use Only

Return to:      Sharon Strauss              or         Judy Hoover

                        ASCLS-PA President                 ASCLS-PA Treasurer                            Date R’ced ____________

                        8 Lakeview Court                       3 White Oak Blvd                                  Computer Date _________

ALL REQUESTS REQUIRE RECEIPTS AND/OR INVOICE

Advance Payment:      Do not use this section if you have a bill or invoice.  Receipts must be forwarded

to the Treasurer as soon as possible.

Program, Function, or Committee                                                                                                                              

Reimbursement:  Reimbursement form must include the bill/invoice or all receipts.  The Chairman of each committee must sign the
reimbursement form.  Forms must be signed by either the ASCLS-PA President or the ASCLS-PA Finance Chair prior to being submitted
to the ASCLS-PA Treasurer for reimbursement.  Use this section also to submit receipts to account for and reconcile monies given previously
in an advance payment.

Program, Function, or Committee                                                                                                      

                                                                                                                        Total:                            ___________

                                                                                                                        Less Advance:               ___________

Make Check Payable to:                                                                  Authorized Signatures:

Printed Name: _                     ___________________                ASCLS-PA President or Finance Chair:

Send to:                                                        _________                                                                                         

Address:          _______________________________                                                                                   

                                                                                                            Date:                                      

Applicant’s Signature: _________________________             Committee Chair: _________________

                                                                                                                                     Date:                          _____

Phone:_____ ______                       Date:   ______                       Treasurer:                                         

Date:                                      

This website last modified 08/01/2007