Equipment Equipment Description License Number # of Hours *Rate per Hour Total 0 1 0 2 3 0 4 0 5 0 6 0 7 0 8 0 0 9 10 0 11 0 12 0 Total Reimbursement 0 Make Reimbursement Payable to: Name: QUAY COUNTY for Supplier No.: 0000054395 Address: P.O. BOX 1246 City: TUCUMCARI NM Zip Code: 88401 DIVISION *Use current equipment rate schedule APPROVAL **Checks are made payable to the governing Indicates body or fiscal agent of fire department. District Forester Date OK TO PAY CERTIFICATION FIRE DEPARTMENT (Chief) Date I certify that the above services were rendered as stated: that they were necessary and proper, that the amounts claimed are just and reasonable and FISCAL AGENT FOR FIRE DEPARTMENT Date that no part thereof has been paid.
Equipment Equipment Description License Number # of Hours *Rate per Hour Total 1 0 2 0 3 0 4 0 5 0 6 0 7 0 8 0 9 0 10 0 11 0 12 0 Make Reimbursement Payable to: Total Reimbursement 0 Name: QUAY COUNTY for Address: P.O. BOX 1246 Supplier No.: 0000054395 City: TUCUMCARI NM Zip Code: 88401 *Use current equipment rate schedule **Checks are made payable to the governing body or fiscal agent of fire department. DIVISION APPROVAL Indicates OK TO PAY District Forester Date CERTIFICATION I certify that the above services were rendered as stated: that they were necessary and proper, that the amounts claimed are just and reasonable and that no part thereof has been paid. FIRE DEPARTMENT (Chief) Date FISCAL AGENT FOR FIRE DEPARTMENT Date
QuayCounty_FireReimbursementform.docx