Funding Request Form

First name

Last name

Phone

Email

Agency

Department

Position

EAC Rep or Group Number

Briefly describe the business purpose related to the expense. Include the event date if applicable.

Who will make the purchases?

Me

My Department

EAC

Number of employees benefiting

Total cost of requested items

I affirm that all information provided is accurate, that the contact information provided is my own, that I am a county employee, and that I am authorized to make this request.

Signature

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