1 APPLICANT COPY ) Capt tal Health Payment Requisition· Accounting Services 11 00 Harley Court 10045-111 St. Edmonton, Alberta T5K 2M5 I PAYEE INFORMATION (Check one only) D Patient D Employee {EE number Invoice Date Invoice Number 'J.D41..16 0 1\S Vendor Number {or S.LN.) Vendor Name 1:) 1 N. C;eS C L..U..!3 . Address P.o. Go'>' 100 o · City ·- .· lOR-ONTO Province/State Postal Codefh:;L... \L-2. CountrY II PAYMENT DETAILS Reason for payment l. \'j. · • • aJ_ <;:_ Jn Is this a contract payment? D Yes (Attach copy of contract if not previously fotwarded) If this is a contract payment, what is the contract date? Number Have goods I services been received? DYes, When? 0 No Are original attachments to be mailed with cheque? (Note 2) DYes Gl-l>k> .. Ill EXPENSE CODES {IN ORACLE FINANCIAL SYSTEM FORMAT) (Departments must provide Complete Coding) Ba! Unit Location Functional Centre e.g. 201 e.g. 9000 e.g. 71135050044 ;;}Ol ctooo '-1 1\\;:) 00000 io " \11\Sooooo"' '' " \I I \S 0 000 0 lo . ' ' L . ' ' ' " " " " .. ,, 1]..-{anadian I D U.S. I D Other IV AUTHORIZATION Account . e.g. 69500001 (o::;).'-11 000' (o ':;\.\.Ill..> 00 0 <Oct.sooooo (p '11000000 If "" "' . Expense Sub-Total GSTif applicable $ Total Payment I confirm that the above items have not been previously paid and the expenses related only to Capital Health business. Requisitioned by (Print name) . \. C 0 (2_R.c\Gf:\ .... _;, Phone# - '31::!5"2... 1-------,--(-S-ig_n_a_tu-re-)-----:; 1'.=-o· "'-'=.'-'-'.c-. .. :-\ . f 'lk;;;-:- v U. fl\ci'LAJ. Phone# - 3A:.5"'-- Approved by (Print name) (Signature) Approved by (Print name) S 1-\E:fy.A L. Phone# - 1 AUTHORIZATIONS SHOULD .BE IN ACcORDANCE WI(H biGNING AUTHORITY POLICY NUMBER FINANCE 4.11J , Notes: ;t:::>H..> 1) All employee payments will be made electronically based on payroll banking information. ./ 0. , :sje 5 2) All cheques and attachments will be mailed out by Accounting Services. Cheques will NOT be pulled and returned to 3) Fully completed payment requisitions received in Accounting Services by MONDAY, 4:00p.m. will be processed that week. 4) Incomplete/improperly authorized payment requisitions will be returned without processing
