Date :_____________

Time:_____________

Checks may be drawn between regular check cycles if the payee of the procurement prohibits credit card payments and the purchase is required to protect life/property or will prevent substantial economic loss or interruption of vital services for the University.

Please follow the purchasing policy for instruction in preparing for a procurement and attach this completed form with approvals indicated below.

The attached request was not submitted for inclusion in the last check cycle for the following reason(s) :

____________________________________________________________________________

____________________________________________________________________________

______________________________________________________(Requester's Vice Chancellor)

______________________________________________________(Vice Chancellor for Business & Finance)

Date Required : ___________ Time Required : __________ Purchase Order No. __________

Vendor : __________________ Special Instructions: _________________________________