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--• <br />CITY OF ROSEVILLE <br />REQUEST FOR PAYMENT <br />A Purchase Order is required if request exceeds $2,000.00 <br />Please PRINT neatly. Thank You. <br />llate vC� � <br />Check Needed By <br />Vendor Name (Check will be made payable to this vendor) <br />Vendor Address <br />Street Address <br />--.� <br />�� Vy`N �``3 <br />State Zip <br />For Payment (Attach Necessary Backup Information such as receipts, etc.) <br />11)r)l�W1pM� D� V�.V� 2�"lr(7W <br />Account Numbers <br />� � � �. � � �/!► .� � <br />Person Requesting Check <br />Department Head Approv <br />�<i�V � <br />Amount <br />• �r <br />Finance Department Approval for Check to be Made Out Prior to Council Date <br />\\Finance\Forms\Reyuest For PaymenLdoc <br />