PURCHASING CARD

Missing Receipt Form

Complete and attach to your bank statement.

I, ______________________________, have either not received or misplaced a Purchasing

Card from _____________________ (vendor name) receipt totaling $______________.

This expense was on behalf of Pacific University. This form is submitted in lieu of the original receipt.

Stmt. Reference No. ______________

Date: _________________

Item(s):

Amount:

_________________________

$________________

_________________________

$________________

_________________________

$________________

_________________________

$________________

_________________________

$________________

_________________________

$________________

I certify that the amounts shown above were expended for Pacific University business purposes.

Cardholder Signature: ___________________________________ Date: _________________

Dept. Administrator/Chairman Signature: ___________________________ Date: ___________

This page is maintained by B. Ray and was last updated in August 2000.

I, ______________________________, have either not received or misplaced a Purchasing Card from _____________________ (vendor name) receipt totaling $______________. This expense was on behalf of Pacific University. This form is submitted in lieu of the original receipt.

Stmt. Reference No. ______________	Date: _________________
Item(s):	Amount:
_________________________	$________________
_________________________	$________________
_________________________	$________________
_________________________	$________________
_________________________	$________________
_________________________	$________________


I certify that the amounts shown above were expended for Pacific University business purposes.

Cardholder Signature: ___________________________________ Date: _________________

Dept. Administrator/Chairman Signature: ___________________________ Date: ___________