Spreadsheet: 02a3fdb9-4075-4373-9920-d7e5eecf7d34
Sheet: Sheet1

Unnamed: 0 | Unnamed: 1 | Unnamed: 2 | Unnamed: 3 | Unnamed: 4 | Unnamed: 5 | Unnamed: 6 | Unnamed: 7 | Unnamed: 8 | Unnamed: 9 | Unnamed: 10 | Unnamed: 11 | Unnamed: 12 | Unnamed: 13 | Unnamed: 14 | Unnamed: 15 | Unnamed: 16
 |  | CHEQUE REQUISITION
 |  | Financial and Administrative Services
 | [NAME] Name: |  |  |  |  | Delivery Method                         (select from menu): |  |  |  | Cheque Payable in             (select from menu)1: |  |  |  |  | Date Required:          (dd/mm/yy)
 | Address:
 |  |  |  |  |  |  |  |  |  | (one currency per report)
 |  |  |  |  |  | Dept: |  |  |  |  |  | Cheque Requisition Forms must be filled out electronically
 | Postal / ZIP Code: |  |  |  |  | Call: |  |  | Ext:
 | This form can be used for all payments made to vendors and individuals outside of the University.  All employee expense reimbursements must be filled out on Employee Expense Reimbursement Form.  Report must 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           dd/mm/yy | Invoice Number &/or Explanation (Include Course Number or SIN if applicable) |  |  |  |  |  | Invoice Total              (including taxes) |  | HST | FINANCE USE ONLY | Account # |  |  |  | Research Code2
 |  |  |  |  |  |  |  |  |  |  | HST CODE | xxx-xxx-xxx |  |  |  | (if applicable)
 |  | For Finance Use Only: |  | TOTALS |  |  |  | 0 |  | 0
 |  | [   ]  CR 111-006-018  $___________ [   ]  CR 111-006-028  $___________ |  |  |  |  |  |  |  | Less:  Advance(s) - Please put OC/UC # in box at left.
 | [NAME] (if different from payee) |  |  |  |  |  |  |  |  | Net Payment |  | **Attach cheque payable to Brock University or pay cash to cashier in Finance department and attach receipt as proof of repayment.
 |  |  |  |  |  |  |  |  |  | Returned to Brock**
 | Print Name
 |  |  |  |  |  |  |  | ACCOUNT ALLOCATION
 |  |  |  |  |  |  |  | Total                                                                   (including taxes) |  | HST | HST  Type | Account #                         xxx-xxx-xxx |  |  |  | Research Code3
 | Signature
PAYEE/ACCOUNT HOLDER/RESEARCHER
 | CERTIFICATION:
 | I hereby certify that the expenses listed on this form were incurred on university business and have not and will not be reimbursed, in whole or in part, by any other source.   I hereby certify that the above listed expenses are in accordance with University policies and procedures.
 | [NAME] (IF APPLICABLE): |  |  |  |  |  |  | 0 |  | 0 | GRAND TOTAL (must equal above)
 | I hereby certify that any amounts on this form that are for research are for the purposes for which the grant  was awarded, have been made in accordance with granting agency requirements, and have not and will not be reimbursed, in whole or in part, by any other source. |  |  |  |  |  |  |  | AUTHORIZED [NAME]
 |  |  |  |  |  |  |  |  | I hereby certify that I have reviewed the above expenses and information attached and that to the best of my knowledge they are true, correct, and complete.  I hereby certify that the above listed expenses are in accordance with University policies and procedures.
 | Print Name |  | Title:
 | Signature |  | Date:  dd/mm/yy |  |  |  |  |  | Print Name |  |  |  |  |  | Title:
 | AUTHORIZED APPROVER >$10,000 (IF APPLICABLE) |  |  |  |  |  |  |  | Signature |  |  |  |  |  | Date:  dd/mm/yy
 | I hereby certify that I have reviewed the above expenses and information attached and that to the best of my knowledge they are true, correct, and complete.  I hereby certify that the above listed expenses are in accordance with University policies and procedures.
 |  |  |  |  |  |  |  |  | Note 1: For other currencies, please complete and attach the Documentation for Wire Payment form.
 |  |  |  |  |  |  |  |  | Note 2: For Research Accounts Only (33x-xxx-xxx):  E1-Equipment >$5000; E2-Equipment <$5000; M1-Materials, supplies and other expenditures; M2-Maintenance; M3-Professional and technical services/contracts; S9-Salaries - Other; T1-Travel; OH-Overhead
 | Print Name: |  | Title:
 |  |  |  |  |  |  |  |  | Finance Use Only |  | Verified by: |  |  |  |  | Date:
 | Signature: |  | Date:  dd/mm/yy
 | 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. 3289, or see www.brocku.ca/finance.
 | version - Aug/12
E1
E2
M1
M2
M3
S9
T1
OH
Mail to Payee Address
Wire Payment
Mail to Depatment
Pick Up in Finance
CANADIAN
US
EURO
POUND STERLING (GBP)
OTHER