SPECIAL REQUEST
PAYEE -
THE PENNSYLVANIA STATE UNIVERSITY
FOR CHECK
( Attach list if
more than one);
University of Pittsburgh
Address
School of Medicine
City /State/Zip
Pittsburgh, Pennsylvania 15213
VENDOR NUMBER (Accounting Use Only) Discount Taken { Social Security No.
Post
Code
CHARGE AS FOLLOWS
Ref | Dept. No.
Fund Name
Fund No. LOhi. CL Prot No.
Amount
VOUCHER NUMBER
BURS AR:
218-12
Pa . Nutri . Ed.
3293F
41 1
$ 500. 00
Mail Check
Mail check with the
attached extra copy.
x Hold and notify:
Name Natalie M. Stover
Phone
5-1717
Date check required
AUTHORIZATIONS:
ADVANCE - (Over $150) state purpose under EXPLANATION,
TOTAL
$ 500 . 00
Department Head
Date
If travel, settlement Dept. Name:
No:
is to be charged to: Fund Name:
No:
Date advance is to be accounted for
Admin. Officer
Date
HONORARIUM of State purpose and duration of visit under EXPLANATION, and
CONSULTING FEES - Social Security No. and current home mailing address above.
PREPAYMENT - Mark Bursar instructions and state purpose under EXPLANATION.
FINAL APPROVAL;
PETTY CASH REIMBURSEMENT - Periodic Summary - All supporting detail attached.
UTILITY - If the name of the payee does not mention the service received, list the service
under EXPLANATION. Invoice attached.
Financial Officer
Date
RENTALS, AUTHORIZED SERVICE, AND REPAIRS - Invoice attached. Explain below.
AUTHORIZED MEMBERSHIPS - Invoice attached. Explain below.
Controller's Office
Date
x
OTHER AUTHORIZED USE - State purpose under EXPLANATION and attach support.
EXPLANATION:
Payment of services as described in attached letters.
. 5-11-76)
Form G1. 60
White - Accounting
Blue - Dean or Admin. Officer
Pink - Originating Office
Source:
ustrydocuments. L

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