Check Request Form

{{company_name}}

{{company_address}}

Phone: {{phone}} | Email: {{email}} | Web: {{website}}

Check Request Form

Check Request Form

Request Details

Date of Request: {{date_of_request}}

Payment Due Date: {{payment_due_date}}

Purpose of Payment: {{purpose_of_payment}}

Amount Requested (figures): {{amount_figures}}

Amount Requested (words): {{amount_words}}

Payee Information

Payee Name: {{payee_name}}

Payee Address: {{payee_address}}

Bank Name (if applicable): {{bank_name}}

Account Number (if applicable): {{account_number}}

SWIFT/BIC Code (if applicable): {{swift_bic_code}}

Requester Information

Requester Name: {{requester_name}}

Department: {{requester_department}}

Contact Number: {{requester_contact_number}}

Email Address: {{requester_email_address}}

Account Coding

Account/Cost Centre to Debit: {{account_cost_centre}}

Project Code (if applicable): {{project_code}}

Budget Line Item: {{budget_line_item}}

Authorization

Requested By (Signature): ____________________________

Requested By (Printed Name): {{requester_printed_name}}

Date: ____________________________

Approved By (Signature - Department Head/Manager): ____________________________

Approved By (Printed Name): {{approver_printed_name}}

Date: ____________________________

Further Approval (if required - Finance Department): ____________________________

Further Approval (Printed Name): {{finance_approver_printed_name}}

Date: ____________________________

Supporting Documentation

Please attach all relevant supporting documentation (e.g., invoices, purchase orders, receipts, contracts).

Checklist of attached documents:

☐ Invoice No: {{invoice_number}}

☐ Purchase Order No: {{purchase_order_number}}

☐ Receipt(s)

☐ Contract/Agreement

☐ Other (Please specify): {{other_documents_specify}}

For Accounts Department Use Only

Check Number: {{check_number}}

Date Issued: {{date_issued}}

Processed By: {{processed_by}}

Date Processed: {{date_processed}}

Payment Method: {{payment_method}}

Notes: {{accounts_department_notes}}