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coE ww <br />Cardholder: Tintle,Robert <br />AMERICAN PUBLIC WORKS <br />NORWICH ADMISSIONS <br />PROCUREMENT CARD TRANSACTION SUMMARY (LOG) <br />Stategic Planning-It's Your Move book <br />Application Fee <br />Total Statement Summary: <br />Account Nbr: 0277 <br />$33.00 1 62900 011 1 8910 1 87 <br />$50.00 1 62900 1 011 1 8910 1 87 <br />I, the undersigned card holder, do hereby certify under penalty of perjury, that, to the best of my knowledge, the materials fumished, services rendered, expense incurred, or <br />other item of indebtedness as charged in the foregoing bill is a true and correct charge against the City of Eugene; that the claim is just and due; and that payment for <br />these charges has not been requested or made from petty cash, department order or other method. /^y' /,-.Ak~ <br />OWIW2010 9:10AM <br />Statement Date: 06117/2010 <br />Car0holder's Signature Date <br />For lost/stolen cards, call: Reviewed and Approved by: <br />Bank of America: (800) 305-7735 <br />Treasury Office: 682-5027 <br />Superv or's Signature Date <br />SCANNE -P A <br />DATE: <br />INITIALS: <br />