Output Explorer

SPECIAL REQUEST
PAYEE -
THE PENNSYLVANIA STATE UNIVERSITY
FOR CHECK
( Attach list if
more than one)
Philadelphia College of Osteopathic Medicine
Address
4150 City Avenue
City/State/Zip;
Philadelphia, Pennsylvania
19131
VENDOR NUMBER ( Accounting Use Only)
Discount Taken
Social Security No.
2:24:78
Post
code
320330, , , 3
CHARGE AS FOLLOWS
Ref Dept. No .
Fund Name
Fund No. | Obi. CL) Prof. No.| Amount
VOUCHER NUMBER
BURSAR:
77178-
218-12
PA. Nutri. Ed.
3293
411
F
$1, 200.00
Mail Check
0
Mail check with the
attached extra copy.
XX Hold and notify:
Name
Natalie M. Stover
Phone
865-1717
Date check required
AUTHORIZATIONS:
ADVANCE - (Over $150) state purpose under EXPLANATION,
TOTAL $1, 200
If travel, settlement Dept, Name:
No:
Department Head
Date
is to be charged to: Fund Name:
No:
Date advance is to be accounted for
Admin. Officer
Date
HONORARIUM or
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

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