Optical Mark Reading Services
OMR Request Payment Authorization

This form cannot be filled in online. Please print, fill in and include it with your OMR Services order.

Method of Payment (check one box)

Name:__________________________________________________

Date:_________________________________

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. _______________________

For Invoice Billing, provide the following information:

Bookeeper's Name__________________________________________________________________

Phone Number_________________________________

Address________________________________________________________________________

City____________________                 State___________               Zip Code__________________

OMR Services Use Only

ITD Initials and Date____________________________

Receipt #_____________________________________

Job #___________________________________