THE
REQUEST TO STATE BOARD FOR
FUNDS
Requestor’s
Name ______________________________________________________________
Address
_______________________________________________________________
Phone_______________________ E-mail__________________________________
Date ____________
Amount
Requested ______________
Explanation/
Use of funds________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
Recipient
Information: NAME ________________________________________________
ADDRESS
_________________________________________________
SIGNATURE____________________________
SIGNATURE __________________________
(Applicant) (Regional Vice-President if applicable)
Approved
by membership date ___________
(if amount exceeds $1000)
Approved
by board date ________________
Form approved 10/00