Cheshire County Republican Committee Check Request Form

Instructions: Please fill in the information and attach a copy of the bill or paid receipt Mail to:

Joseph Feuer, CCRC Treasurer
PO Box 477
Marlow, NH 03456

Name of individual making the request (Print name please):

__________________________________________________________________________

Date: __________________

REQUEST for REIMBURSEMENT (Proper documents must be attached)

PAY VENDOR from ATTACHED RECEIPT  (Proper documents must be attached) 

  ADVANCE NOTICE of DIRECT BILLING 

PAYABLE TO: ___________________________________ AMOUNT $ _______________

MAIL CHECK TO:
(Name:)_______________________________________________________________________________ (Address:)_____________________________________________________________________________
__________________________________________________________________________

DATE (S) of EVENT/EXPENSE: __________________________________________________

PURPOSE: (be specific - OK to use reverse):        

SIGNATURE: _______________________________________________   DATE: _____________

APPROVAL: ________________________________________________  DATE: _____________

PLEASE KEEP A COPY FOR YOUR RECORDS                                                                                    CCRC Billing 7/09