Medical Student Government

Purchase Order / Reimbursement Request Form

Type of Request
	This is a purchase order form. I am requesting goods/services from a Penn approved vendor. Penn will pay; this won’t cost me a dime. So that the purchase order may be processed in time, I am submitting this form a minimum of 4 business days before my event.
	This is a reimbursement request. I chose not to use a purchase order and a Penn approved vendor so it will take 4-6 weeks for me to receive a reimbursement check. I could have avoided this. I also have the REQUIRED itemized receipt and list of people who attended the event ready to be submitted.
	Non-MSG entry. This option should ONLY be used under specific instruction from the MSG Treasurer or Suite 100.
	MSG Treasurer Entry. This option is ONLY for the MSG Treasurer's use.
Student Group Name:
Your Position:
Your First Name:
Your Middle Name [optional]:
Your Last Name:
Penn Card #:
Last 4 Digits of SSN:
Contact Information
Phone Number:
Address:
E-mail:
Expense Information
This request is for:
	food, no alcohol (5211)
	office supplies (522x)
	entertainment (5214)
	other:
Total amount (including tips but not taxes):	$
List of items purchased with money:
If Purchase Order ONLY:
Vendor Name (if Penn-approved)	[see list of approved vendors]
Vendor Phone
Event Information (Enter "N/A" for each if this is not an event.)
Date of Event:	MM/DD/YYYY (Enter date of purchase if this is not an event.)
Time of Event:
Name of Event:
Location of Event:
Please describe your event clearly (including time of event, expected attendance, name of speaker, topic of talk, etc.):
Post Event Information [optional] (This info will be requested in future email if this request is for a PO.)
Number of attendees:
Advice for future organization leaders: Do you feel this event was successful? Should a similar event be hosted in the future? Are there any changes you would make?

 

 

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