Equipment Equipment Description License Number # of *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: VILLAGE OF SAN JON for SAN JON FIRE DEPARTMENT Supplier No.: 0000054455 Address: P.O. BOX 37 City: SAN JON State: NM Zip Code: 87733 DIVISION *Use current equipment rate schedule APPROVAL **Checks are made payable to the governing Indicates body or fiscal 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 *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: VILLAGE OF SAN JON for SAN JON FIRE DEPARTMENT Address: P.O. BOX 37 Supplier No.: 0000054455 City: SAN JON State: NM Zip Code: 87733 *Use current equipment rate schedule **Checks are made payable to the governing body or fiscal 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
VillageofSanJon_FireReimbursementform.docx