Check One ®        DIRECT PAY COVER SHEET
						EMPLOYEE REIMBURSEMENT		REV'D 2-13-02
						OTHER REIMBURSEMENT
BANNER DOCUMENT NUMBER ®		TRANSACTION				VENDOR INVOICE
(CAPITAL “I”, ZERO, SIX DIGITS)		DATE				MISCELLANEOUS PAYMENT
PAYEE ®						AUTHORIZED APPROVER SIGNATURE		DATE
AMOUNT						FUND - ORG - ACCOUNT - LOCATION		PICKUP CODE
DEPARTMENT ®						USER DEFINED
RESPONSIBLE PARTY ®						USER DEFINED
EMAIL ADDRESS ®		PHONE EXT				USER DEFINED
® = REQUIRED ENTRY
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