2043 College Way
Forest Grove, OR 97116-1797
503-357-6151
Limit: $50.00
US Bank Corporate Card
Missing Receipt Form
Valid only for Visa Card
I, ____________________________, have either not received or misplaced
a US Bank Corporate Card receipt totaling $ _____________.
This expense was on behalf of Pacific University.
This form is submitted in lieu of the original receipt.
Reference # ________________________ Date: _____________________
Supplier: __________________________ Amount: __________________
Items Purchased: ______________________________________________
_____________________________________________________________
_____________________________________________________________
I certify that the amounts shown above were expended for Pacific University business
purposes. Two signatures are required to validate this form.
____________________________________
Cardholder Signature
Date
__________
____________________________________
___________
Department Administrator/Chairman
Date
Rev 08/15
TC-2