Payment Request

To be completed by Vendors or individuals to request payments from SAMA – US office

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Step 1 of 2

Name of Company

First Name

Middle Initial

if applicable

Last Name

Email Address

e.g. +249912345678

photo ID

Click or drag a file to this area to upload.

.pdf, .png, .jpg, .jpeg format driving license, or passport or State ID

Amount requested in numbers (US$)

Amount requested in letters (US$)

Reason for payment

Invoice

Click or drag files to this area to upload. You can upload up to 2 files.

.pdf, .pdf, .png, .jpg, .jpeg format

Mailing Address

Address Line 1

Address Line 2

City

State

Zip Code

Payment will be sent by registered mail to address above

Expert in Infectious Disease Needed