Invoice Template - Excel 5 by moneu

VIEWS: 0 PAGES: 2

									                                               RESEARCH DEVELOPMENT AND ADMINISTRATION
                                               Sponsored Projects Administration
                                               Mail code: AD220 • 2525 S.W. First Avenue, Suite 220 • Portland, Oregon 97201-4753
                                               503 494-0355 • Fax 503 494-1191
                                               www.ohsu.edu/research/rda/spa



                                                                 Invoice Number:
                                                                 Invoice Date:
                                                                 Due Date:                               Upon Receipt

BILL TO:                                                        Remit payment to:
  Name:                                                            Oregon Health & Science University
  Attn:                                                            Attn: Cash Management / Sponsored Projects Admin.
  Address:                                                         2525 SW 1st Avenue, Suite 220
  Address:                                                         Portland, OR 97201-4753
  City/State/Zip                                                   Tax ID#: 93-1176109

SERVICES FOR:
  Study Title:                                                   PI:
                                                                 IRB #:
                                                                 Protocol / Study #:
                                                                 Sponsor’s PO#:
                                                                 Award / Project #:


    Quantity                                Description                                      Unit Price                 Total
                                                                                                               $                 -
                                                                                                               $                 -
                                                                                                               $                 -
                                                                                                               $                 -
                                                                                                               $                 -
                                                                                                               $                 -
                                                                                                               $                 -
                                                                                                               $                 -
                                                                                                               $                 -
                                                                                                               $                 -
                                                                                                               $                 -
                                                                                                               $                 -
                                                                                                               $                 -
                                                                                                 Total         $                 -

                                               Previous Unpaid Invoices
                            Date                         Invoice Number                         Amount




                                                 Total Previous Unpaid Invoices         $                  -

Approved:




Type PI's Name:                               PI's Signature:   Re                                             Date:


   Please reference the PI's name and the Study Number on the check and return a copy of this invoice with the payment.

If you have any questions regarding this invoice, please contact:

                                                503-494-XXXX
Name:                                         Phone:                                   Email:
                                                                                                                         Revised 4/17/07
                                                                                            Department / Division
                                                                                                  Address




                                                                      Invoice Number:             DEPT - 2004-06
                                                                      Invoice Date:               May 21, 2004
                                                                      Due Date:                            Upon Receipt

BILL TO:                                                             Remit payment to:
  Name:            A Good Sponsor                                       Oregon Health & Science University
  Attn:            Attn: M.Y. Rep                                       Attn: Cash Management / Sponsored Projects Admin.
  Address:         41 Research Ave.                                     2525 SW 1st Avenue, Suite 220
  Address:         Building #1, Suite 100                               Portland, OR 97201-4753
  City/State/Zip   Industry City, MA 02453                              Tax ID#: 93-1176109

SERVICES FOR:
  Study Title:                                                        PI:                         Dr. A. Grant Investigator
  A Phase II, Randomized, Double-Blind, Placebo-Controlled, Multi-    IRB #:                      9999
  Center, Parallel-Group, Study to Assess the Efficacy, Safety and    Protocol / Study #:         AGS-4431
  Tolerability of a Drug or Device in Human Subjects                  Sponsor’s PO#:              4900045
                                                                      Award / Project #:          AOHSU9999 / GOHSU9999A


    Quantity                                   Description                                          Unit Price              Total
        2          Contract fee for completed Subjects                                        $          5,300.00   $         10,600.00
                                                                                                                    $               -
        1          Contract fee for partial completion (2 visits)                             $          1,007.00   $          1,007.00
                                                                                                                    $               -
                                                                                                                    $               -
                                                                                                                    $               -
                                                                                                                    $               -
                                                                                                                    $               -
                                                                                                                    $               -
                                                                                                                    $               -
                                                                                                                    $               -
                                                                                                                    $               -
                                                                                                                    $               -
                                                                                                       Total        $         11,607.00

                                                  Previous Unpaid Invoices
                              Date                          Invoice Number                            Amount
                         March 15, 2004                      DEPT - 2004-05                   $         21,200.00
                        February 4, 2004                     DEPT - 2004-04                   $         10,600.00


                                                     Total Previous Unpaid Invoices           $         31,800.00

Approved:


  Dr. A. Grant Investigator
Type PI's Name:                                  PI's Signature:     Re                                             Date:


   Please reference the PI's name and the Study Number on the check and return a copy of this invoice with the payment.

If you have any questions regarding this invoice, please contact:

  Joan Invoicecreator                               503-494-XXXX
Name:                                            Phone:                                      Email:
                                                                                                                            Revised 4/17/07

								
To top