Spreadsheet: 03fd4a01-b40b-4ec2-8bb6-f4df3755aab3
Sheet: Sheet1

Unnamed: 0 | Brock University | Unnamed: 2 | CHEQUE REQUISITION | Unnamed: 4 | Unnamed: 5 | Unnamed: 6 | Unnamed: 7 | Unnamed: 8 | Unnamed: 9 | FOR EXTERNAL VENDORS | Unnamed: 11 | Unnamed: 12 | Unnamed: 13 | Unnamed: 14 | Unnamed: 15
 | Financial and Administrative Services |  |  |  |  |  |  | Date Required:
 |  |  |  |  |  |  |  |  |  |  | (mm/dd/yy)
 | [NAME] Name: |  | [ |  | ] | Mail to payee address |  |  |  | Cheque Payable in: |  | [ |  | ] | CDN $
 | Address: |  | [ |  | ] | Mail to department |  |  |  |  |  | [ |  | ] | US $
 |  |  | [ |  | ] | Will pick up from Finance |  |  |  |  |  | [ |  | ] | Other currency 2
 | Postal / ZIP Code: |  |  |  |  | Call: |  |  | Ext: |  | NOTE:
 |  |  |  |  |  |  |  |  |  |  | One currency per report                           Attach proof of exchange rate
 | NOTE: | This form is for payment of external vendors. Internal payments to Faculty and Staff should be submitted on either a Travel and Related Expenses Report or Refundable Expense Report
 | Use this form if payment could not be processed through any of the following payment streams:
 |  | 1.   Purchase order (e.g. emergency purchase, no predetermined value for consulting fees)
 |  | 2.   Procurement card (e.g. not available)
 |  | 3.   [NAME] cash (e.g. amount > $75 or no access to [NAME])
 | NOTE: | Report should be submitted to Accounts Payable with original receipts/invoices attached in order listed below.
 |  | Attach any documents that are to be mailed with the CHEQUE.
 | Date      mm/dd/yy | Invoice Number &/or Explanation |  | Course Number        or SIN (if applicable) 1 |  |  |  | Invoice Total   including GST |  |  | Research Code (if applicable) 3 | Account #
 |  |  |  |  |  |  |  |  |  | GST |  | xxx-xxx-xxx
 |  |  |  | TOTALS |  |  |  | 0 |  | 0
 | Note 1: Course Number and Location required for Faculty of Education, Social Insurance Number (SIN) required if payment is for services provided by an individual who is not an employee of Brock University.
 | Note 2: For other currencies, please complete and attach the Documentation for Wire Payment form.
 | [NAME] (if different from payee)
 | Print Name:
 | Signature: |  | Date:
 |  |  |  |  |  | [NAME]/dd/yy
 | CERTIFICATION:
 | I hereby certify that the expenses listed on this form relate to university business and have not and will not be reimbursed, in whole or in part, by any other source.
 | [NAME]:
 | I hereby certify that any amounts on this form that are for research purposes are for the purposes for which the grant was awarded and have not and will not be
 | reimbursed, in whole or in part, by any other source.
 | ACCOUNT HOLDER/RESEARCHER
 | Print Name: |  | Title:
 | Signature: |  | Date:
 |  |  |  |  |  | [NAME]/dd/yy
 | IMMEDIATE SUPERVISOR
 | Print Name: |  | Title:
 | Signature: |  | Date:
 |  |  |  |  |  | [NAME]/dd/yy
 | Note3- For Research Accounts Only (33x-xxx-xxx):
 | E1 = Equipment  M1 = Materials, supplies and other expenditures   M2 =  Maintenance   M3 - Professional and technical services/contracts
 | S9 = Salaries - Other    T1 = Travel   OH = Overhead
 | Finance Use Only |  | Verified by: |  |  |  |  |  |  | Date:
 | Brock University protects your privacy and your personal information.  Personal information on this form is collected under the authority of The Brock University Act, 1964, and in accordance with the Freedom of Information and Protection of Privacy Act (FIPPA) for the administration of the University and its programs and services.  Direct any questions about this collection to Financial and Administrative Services at Brock University at (905) 688-5550, ext. 4600, or see www.brocku.ca/finance.