Please Provide the Following Personal Information:

Your Name:            

Title:                        

Co-op/Company:   

Mailing Address:   

City, State & Zip:   

Business Phone:    (include area code & extension)

Fax:                                

Email:                     

Please Provide the Following Check Request Information:

Who is check to be made payable to?:       

What is being paid for?:                         

When is the check required?:                

Any Special Instructions?:                          

Make check payable to:  Requestor (you)    or    Vendor

Total check amount requested: $

Will you be mailing a hardcopy invoice (see note below):  Yes    or    No

Please enter any other comments in the space provided below:

Please Note:  After clicking the submit button below, please print the confirmation page that is shown, attach it to the invoice for payment (if applicable) and mail both to the address below. If no hardcopy invoice is required, no further action is needed. You will soon receive a reply from the affiliate President as to the status of your request. To email the President or Treasurer visit our officers page.                       Mailing Address:                                         Jon A. Harrison, C.P.M. ~ ISM-CU Treasurer Procurement Services Manager PowerSouth Energy Cooperative P.O. Box 550 Andalusia, AL 36420 Phone: 334-427-3274 Fax: 334-222-6387 jon.harrison@powersouth.com