RECEIPT/DOCUMENT NUMBER(Displayed on EIC):________________________
TRAVEL AUTHORIZATION NUMBER:____________________________
DATE OF PURCHASE:__________________________
MERCHANT NAME:_________________________________________
CARDHOLDER NAME:________________________________________
DESCRIPTION OF PURCHASE:_________________________________________________
________________________________________________________________________________
TOTAL PURCHASE AMOUNT:__________________________________
RECEIPT WAS (CHECK ONE)_____LOST_____NOT OBTAINABLE
Please provide brief explaination of why receipt was not obtainable:
________________________________________________________________________________
________________________________________________________________________________
I, _____________________________________, the undersigned do certify that the above purchase was made for University of Arkansas travel.
________________________________________
CARDHOLDER SIGNATURE