2006   Expense Check Request

Michigan State Chapter

Name: ___________________________________________________________________

Office/Chair:_______________________________________________________________

Commitee:_________________________________________________________________

Purpose:__________________________________________________________________

Dates: ____________________________________________________________________

Address to be mailed to: _____________________________________________________

_______________________________________________________

_______________________________________________________

Explanation of Expense:                                                                               Amount:

__________________________________________________                _______________

__________________________________________________                _______________

__________________________________________________                _______________

__________________________________________________                _______________

                                                                         Total Expense                  ________________

**Expenses should be submitted within 45 days of event/travel for reimbursement.

Submit to:   Fran Johnson                                                                            Ck No__________

47766 Van Dyke                                                                                      Date____________

Shelby Twp., Mi.  48317 

586-843-6335

eMail: fjohnson@cbschweitzer.com  

*Were you also partly reimbursed by another entity?

If so how much $_________________ this will help us with our yearly budget.