Local's Name *

First Name

Last Name

Program Local Participates In *

City Local

Homestead Local

Day Local (HUB)

Name of staff member entering this payment information *

First Name

Last Name

Date Payment Received *

MM

DD

YYYY

Payment Type *

Full payment received

Partial payment received

If partial payment received, scheduled date for remaining balance to be received

MM

DD

YYYY

Method of Payment *

Bank Transfer (preferred)

PayPal

Check/Money Order (must receive pre-approval)

Cash (must receive pre-approval)