Request for Withdrawal of Funds Form

Request for Withdrawal of Funds

First Name

Last Name

PRCC Email

Account Type

Designated Account (Non-Athletic)

Athletic Account

Are you seeking

Pre-Approval

Reimbursement

Account Name

Amount of Withdrawal

Purpose of Withdrawal

Upload receipts or documentation of expenses

Choose File

__________________________________________________________________________________________________________________________________________

Check Payable

Address

Address Line 1

Address Line 2

City

State

Zip Code

__________________________________________________________________________________________________________________________________________

If the check is to be sent to someone other than the payee, give the correct name and address below.

Name

Address

Address Line 1

Address Line 2

City

State

Zip Code

__________________________________________________________________________________________________________________________________________

Additional Information (If necessary)

__________________________________________________________________________________________________________________________________________

For all athletic accounts, please list Athletic Director for authorization. For non-athletic accounts, please list Club Sponsor, Department Chair, Director, Dean, VP or main account manager for authorization purposes.

Person Authorizing the Withdrawal

Authorizing Person’s PRCC Email Address

Authorizing Person’s Phone Number