Hampstead Lions Club

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P.O. BOX 171
Hampstead, NH 03841
Treasurer: Sam Longbook
dgsam44h@comcast.net
603.329.5603

Check Request Form

A check request will be completed when a member is being reimbursed for expenses. This form will serve as a record for the Treasurer, identifying why a check was issued and where payment is to be sent. After completing the Form, Print a copy and send to the Treasurer.

Date of Request *

YYYY

Make payment to Name *

Address *

Phone *

Email *

Amount of Reimbursement *

Project *

Receipt(s) Attached *

YES

Required

Comments

Signature *

Date Submitted *

YYYY

Submit

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