WESTERN ASSOCIATION OF THE NEW YORK CONFERENCE
OF THE UNITED CHURCH OF CHRIST

CHECK REQUISITION

Date: _______________________________

Check Payable To: ______________________________________________________________

Address: ______________________________________________________________________

            _______________________________________________________________________


Description: ____________________________________________________________________

       __________________________________________________________________________

Person requesting check: __________________________________________________________

Participant Contributions to this Event: (i.e. what portion of cost is paid by participants, and what
    portion comes out of the Western Assoc. budget?) ____________________________________

    _____________________________________________________________________________

Authorization: ____________________________________________________________________

Amount: $ ____________________________

PAYMENT INFORMATION

Check Number: _____________________

Check Date: ________________________

Account Number: ____________________

(Form 09/04, Updated 03/05)
Mail To: Roslyn Morgante, Accountant, Western Association NY Conference UCC, One Fox Run Ln, Buffalo, New York 14127

To print this form, press "Ctrl" and "P" to bring up your computer's print screen.  Then print, fill it out & mail it in.
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