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: CITY OF CLOVIS for CLOVIS FIRE DEPARTMENT Supplier No.: 0000054320 Address: P.O. BOX 760 City: CLOVIS State: NM Zip Code: 88102 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 *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: CITY OF CLOVIS for CLOVIS FIRE DEPARTMENT Address: P.O. BOX 760 Supplier No.: 0000054320 City: CLOVIS State: NM Zip Code: 88102 *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
CityofClovis_FireReimbursementform.docx