Check Request

Please use this form to submit for expense reimbursements or 3rd part check requests.

Only CBCA Executive Board Members and Event Chairs may use this form to submit a request. If you are not an Executive Board Member or Event Chair, please provide the information and receipts to the proper person to submit the request on your behalf.

Fields marked with an * are required.

Request Details

First Name *

Last Name *

Email *

Phone

Check Payee Name *

Total Check Amount *

Was a CBCA debit card used for this purchase? *

Mail the Check? *

Do you want the check mailed? Is so, select "Yes" and provide mailing address below.

Address Line 1

Address Line 2

City

State

Postal Code

Payee Email

Payee Phone *

Expense Detail

Committee *

Purpose *

Please list each expense and explain the purpose for each line item:

Description (items purchased) - General Ledger Account (supplies, permits, etc.) - Item $ Amount

Upload Receipt File

If you have the receipt please upload it.

20MB max

Consent and Acknowledgment Statement

Yes, I agree and affirm the above statement * By checking the "Yes" box below, I acknowledge and agree that this action constitutes my electronic signature, and that it is legally equivalent to my handwritten signature. I certify that the information provided is true and complete to the best of my knowledge. I understand that my electronic acceptance is binding and carries the same legal weight as a signed, written document.

Today's Date *

Check Request

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Check Request

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