Request for Third Party (Vendor) Payment Form

The purpose of this form is to explain and authorize charges appearing on a vendor invoice or statement. Use this form ONLY if invoices or statements will be sent directly to the NDLA Treasurer by the vendor.

If you possess the vendor invoice or statement, use the PDF version of this form found on the NDLA web site and include the invoice or statement with your request.

* Note that this request must be sent from the e-mail address of the person making the request.

Name of Vendor:
Address of Vendor:
Date of Purchase or Service:
Expense Amount: $
Description of Purchase or Service (include quantity):
Purpose of Purchase or Service:
Name of NDLA Budget Category (i.e. Executive Board, Section / Round Table etc.):
Name of NDLA Member Responsible For Expense:
I authorize that the expenses on the vendor invoice / statement are accurate:
Your Name (authorization):
Your E-mail Address:
Date of Request:
Your Day Time Phone Number: