Cash Reimbursement Authorization Request
To:
NCSU Accounts Payable
From:
Department of Statistics
Date: ______________________
Campus Box # 8203
This is to certify that the following individual was authorized to purchase the item(s)/service(s), for the amount specified, from the following
vendor(s), on the following date(s) as listed below:
Name: _______________________________
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N
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A
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_______________________________
Store(s): ______________________________
Total of receipt(s): _____________________
Date:
_____________________
Account Number: _____________________
Item(s) Purchased:
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
Purchaser’s Signature: ________________________________________________________________
COMMENTS
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Authorized by: ___________________________________
(PI / Department Head)
Date: ___________________________
Authorized by: ____________________________________
(Dean of PAMS)
Date: ___________________________
Home Address: _______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________