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Associated Students of Claremont McKenna College

Check Request

Please see the ASCMC Reimbursement Guidelines before seeking reimbursement. Nonconforming requests will suffer time penalties and potential denial. Attach original itemized receipts, invoices, and other supporting documentation.  

Organization and Account Holder Information

Name: Phone:

Position: Email:

School: Organization:

Payee Information

Same as Above

Name: Email: Phone:

School: Box# (if applicable):

Address (if not on campus)

Street: City: State: Zip:

 

Date of Purchase(s) or Event(s): Time: Approximate Number of Participants:

Description of activities, purchase, or service obtained :

Please follow the following format with the box below:
Good 1, Price
Good 2, Price
Good 3, Price
etc...

Line item breakdown of expenses :

Does this request include non-perishable items such as equipment?

Any equipment purchased with ASCMC funds becomes the property of ASCMC and must be surrendered upon the request of an ASCMC Officer. Failure to comply is considered theft, and offenders will be prosecuted under ASCMC and/or CMC codes and procedures, and/or under local, state and federal law.

Source of Funds:

Club Budget: $ CO: $ Executive Board General Fund: $
Senate: $ Senate Trips: $
DAC: $ SAC: $ SLC: $ President's Fund: $

Other: $

Dormitories

Is TNC

Appleby: Apartments: Claremont: Auen: Beckett: Benson: Berger: Boswell: Fawcett: Green: Marks: Phillips: Wohlford: Stark:

Amount for:

Supplies $ Services $ Alcohol (up to 15% alcohol by volume) $ Total $

Under penalities of perjury, I declare that I have exmained this request and to the best of my knowledge and belief, it is true, correct, and complete.

Initial Here:

After you submit, you will be presented with a transaction number. Please put all your receipts in an envelope labeled with the transaction number and turn it into Storyhouse #1540. When your request is approved, the payee on this form will receive a check in their box.

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