Check Request Form

Mile City Check Request Form
*Receipts, invoices and/or other supporting documentation must be attached
Make Check Payable To*
If mailing please provide an Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Department Head*
Name of Person Submitting*
First Last
Email*
*Please attach all receipts. All check requests must be submitted within 30 days.
Itemized List*
Date of Service Department/Purpose Account Number Location (Plymouth, Lyon, Hikari) Amount Requested

Please fill in the columns with the correct info. Click + to add more rows. If you would like to split between accounts, please do a separate line for each account with the split total.
Memo On Check
Please upload all receipts for purchases listed above.
Drop files here or

Max. file size: 50 MB.

Date of Service	Department/Purpose	Account Number	Location (Plymouth, Lyon, Hikari)	Amount Requested