Declining Balance Card Request
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Declining Balance Card Request. Date Requested _________________ Date Card Required _______________ Department _________________________ Phone Number ___________________ Cardholder’s First Name ________________ Last Name ______________________

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Declining Balance Card Request

Date Requested _________________ Date Card Required _______________

Department _________________________ Phone Number ___________________

Cardholder’s First Name ________________ Last Name ______________________

Dollar Amount Requested $______________ Employee ID Number ______________

GL Code:

Reason for request: (please give specific travel dates or details of business need)

_______________________________________________________________________

_______________________________________________________________________

_______________________________________________________________________

_______________________________________________________________________

_______________________________________________________________________

Please print legibly

Authorized Signatures:

___________________________________________________________________________

Cardholder’s Signature Print Name Date

___________________________________________________________________________

Supervisor Approval Signature Print Name Date

(must be authorized signer for GL above)

___________________________________________________________________________

Provost or Additional Approval Print Name Date

To be completed by Business Office:

Date received ____________ Approved Declined Request No _______

Reviewed by ______________ Card Ordered __________ Card Received _________


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