Please remit with registration materials following the first and or last class session.
INVOICE REIMBURSEMENT
Date: _____________
Agency Information
Name: _______________________________________________________________________________
Business/Agency Name: _________________________________________________________________
Agency Address: _______________________________________________________________________
_______________________________________________________________________
City
Zip
_____________________________________________________________________________________
Course Information
Course Title: __________________________________________________________________________
Course K Number: K ____________
Credits: ________
Term of Course Offering: __________
Year: _________
_____________________________________________________________________________________
Reimbursement
Line 1
____________X __________ = __________
(# of credit
students enclosed)
Line 2
$50
(course fee total)
Total
(PSU credit + agency)
X __________X __________= __________
(PSU credit fee )
(# of credits)
Line 3
(# of credit students
enclosed)
Total
(PSU credit fee)
Line 1 minus Line 2 = __________
(total due agency)
Agency Remittance
75% Remittance (total agency - 75%)
OR
25% Remittance (total agency - 25%)
= _________X
75%
(Line 3)
= __________
(Total)
= _________X
(Line 3)
25%
= __________
(Total)
________________________________________________________________________
Remit To
ATTN: SES Registration
School of Extended Studies
PO Box 1393
Portland, OR 97207-1393
(envelope provided)
*The agency must attach a roster of student names, social security numbers, addresses, and phone numbers with the students
checks made payable to PSU. A copy of this invoice and the class roster will be returned with your payment.
-----------------------------------------------------------------------------------------------------------------FOR OFFICE USE ONLY
Agreement # _________________________
Date paid: ___________________________
PSU Invoice: ________________________
Agency Vendor # or SS #: _________________
Index Code: ____________________________
I:\ce\dce\regpkt\invoicenew Revised 6/30/05
Enrollment Adjustments
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