Payment Requisition

Vendor Information

*Vendor Name

*Vendor Number

*Country

*Which country/countries was the service performed or product used?

*Vendor Relationship with Loyola

You are not required to fill out this form. Please fill out an HR form instead.

*Vendor Payment Method

ACH Check Wire Transfer
(Upon submission, you will be asked to invite the vendor to submit a W-9 form electronically.)

Invoice Number

*Invoice Date

*Total Invoice Amount

First date of service /Delivery date

Requested Due Date
(Please allow AP 10 business days to process all payment requests.)

*Payable To

Vendor Email

Address on File

Is there a new address?

Yes No

*City

*State

*Zip Code

Remit To Code

Purchase Order Number

Distribution of Expenses

*Accounting Unit or Activity	*Account/Account Category	*Amount

Total Distribution Amount: