Lone Star Model A Ford Club

Date	Vendor	Description	Amount
		Total

Remit to Payee (One Payee per form)            Name Address City,TX,Zip

Requestor's Name: Signature: Phone: Email: Date:

Receipts / Invoice Enclosed Yes NO

Reviewed and Approved by

President:   Signature: _____________________ or For the President's purchases
Date:
Check Number
Comments:
Treasurer: Signature:________________________________ Date:

To get reimbursed, fill out the form, print it, sign it, and scan or mail it to the president.
You can also request a Word document where you can fill in the form.
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