Payment & Order Authorization Form

From:

(Institution)

To:

Ref #

Date:

Address:

You are hereby authorized to release payment to ____________________________________________ or order

a sum of ________________________________________________________ Dollars ($_________________)

Items

Account to be charged :

Description

Price

Amount

Fund ________________________________________

Dept ________________________________________

School _______________________________________

Account no ___________________________________

Authorization Raised by: (Name & Signature)

Total

Notes / Comments:

Approved by: (Name & Signature)

Important: A copy of the completed form should be retained for records and auditing purposes.

0 votes

Parent category: Business