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National Center on Deafness (NCOD)
(NAT'L CENTER ON DEAFNESS
TEL. NO. (818) 677-2054
FAX NO. (818) 677-7192
MAIL DROP: 8267
A.S. Service Request Chargeback Form
LINE
REQUIRED FIELDS:
ACCOUNT:
FUND:
DEPT ID:
PRGM:
CLASS:
PROJECT/GRANT:
REQ #:
 
REQUESTER:
DEPARTMENT:
EXT / FAX:
MAIL DROP:
DESCRIPTION: (Max 12 Char)
ESTIMATE REQUESTED:
DATE NEEDED:
Authorized Signature: _______________________________________________ PRINT NAME:
Auxilary Use Only - PLEASE ATTACH COPY OF P.O.
BUSINESS UNIT:
BLANKET PO?
AUXILARY PO #:
GRANT EXPIRATION DATE:
ESTIMATED/NTE AMOUNT:
 
 
 
ACCOUNT:
FUND:
DEPT ID:
PROGRAM:
CLASS:
PROJECT/GRANT:
 
 
Auxiliary Authorization:__________________________________________ Date Approved:
Print Name:
AUXILIARY WILL BE ASSESSED A $25 LATE FEE PAYABLE TO THE SERVICE PROVIDER FOR EACH 30-DAY PERIOD BEYOND THE BILLING DATE.
Service Department Use Only
ESTIMATED COST: ACTUAL COST: DATE COMPLETED: BILLING REFERENCE: PROCESSOR:
PLEASE EXPLAIN FULLY & CLEARLY (Give description & location of services including the contact person & email address).
NOT TO EXCEED 5 LINES.
line
PLEASE ENTER YOUR SERVICE REQUEST INFORMATION
Please send completed form to: Nat'l Center On Deafness , Mail Drop 8267
*Requestor must provide copies of all Flyers, Announcements, Meetings, Agendas, Scripts, etc.
Requests must be received at least 5 working days in advance!
EVENT INFORMATION:
SERVICES REQUESTED:
   
Date of Event:
Interpreter:
Start Time:
Notetaker:
End Time: C-Print:
 
Realtime Captionist:
*** FOR NCOD USE ONLY ***
   
Special Instructions: Assigned To:
___________________________________________ __________________________________________
___________________________________________ __________________________________________
___________________________________________ __________________________________________

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