Purchase Order No - DOC

							Purchase Order No.___________           CLAIM FORM         Department

                                   Mid East Suffolk Teacher Center
                                        Ridge Primary Center
                                          105 Ridge Road
                                          Ridge, NY 11961

Name of Claimant

Address of Claimant ___________________________________________________________
                           (street)            (town)         (state)   (zip)

Claimant’s Invoice No.                            Inv. Date                 Terms
                                               INVOICE
Quantity               Materials, supplies, services (Itemize)        Unit Price      Totals


Payment for the Design Your Own Staff Development Program:                            $

           Workshop Title:

           Dates:

           Location:




                                                       Total amount of Claim $


This is to certify that the work, labor, services, materials and supplies charged in the above
account and included in the same, amount of $_______ have been actually performed for,
furnished and/or delivered to the Mid East Suffolk Teacher Center, Ridge, NY; that said claim
is just, due, and unpaid and that there are no offsets against the same; that the items and
specifications therein are correct; that the sums charged are reasonable and just; that no
payment has been made on account thereof, except as included or referred to in such account
or claim.




      Claimant’s Name                         Signature of Claimant                 Date