Credit $

Overtime Acct #

Credit $

Labor Acct #

Credit $

Overhead Acct #

Credit $

Material Acct #

Processed by

Debit $

Acct #

DO NOT WRITE BELOW THIS LINE – PHYSICAL PLAN USE ONLY

Physical plant comments:

15.  Date received

14.  Estimated Amount

13.  Estimate required?

12.  Approved by

11.  Authorized amt.

10.  Acct to be charged

9.  Date

8.  Authorizing signature for transfer of funds

Section II -  AUTHORIZATION

7.  Description of Work (attach sketch if required).  If applicable, list scheduling restrictions/room availability.

6.  Signature of department chairperson

5.  Location of work (building & room)

4.  Today’s Date

3. Phone number

2. Name and location of requester

1.  Department

Section I

INSTRUCTIONS FOR COMPLETING FORM ARE ON REVERSE, USE TYPEWRITER OR PRINT LEGIBLY.  PRESS HARD.