Optical Mark Reading Services
OMR Request Payment Authorization
Please print, fill out and include with your OMR Services order.

Method of Payment (check one box)

Personal Check
Money Order
Service Unit Billing
Invoice

Name:__________________________________________________

Date:_________________________________

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For Service Unit Billing, provide the following information:

FAS Account No._____________    Object Code _____________      Project No. ______________              

Amount approved to be billed for: _______________

In order to receive goods/services listed in this contract/application, I certify that the FAS account indicated above is correct and is authorized to be used for the duration of the project/activity.

SUB Prior Approval Signature: ____________________________              

Department __________________________

Bookeeper's Name__________________________________________________________________

Bookkeeper's Box No. _______________________

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For Invoice Billing, provide the following information:

Bookeeper's Name__________________________________________________________________

Phone Number_________________________________

Address___________________________________________________________________________________________

City____________________                 State___________               Zip Code__________________

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OMR Services Use Only

ITD Initials and Date____________________________                    

Receipt #_____________________________________

Job #___________________________________