Declining Balance Card Request Staff/Faculty Declining Balance Card Request Date Requested _________________ Date Card Required __________________ Department _________________________ Phone Number ______________________ Cardholder’s First Name ________________ Last Name __________________________ Dollar Amount Requested $______________ Employee ID No. ______________________ GL Code: Reason for request: (please give specific travel dates or details of business need). Include how long the funds are needed, i.e. when funds should expire. _______________________________________________________________________ Please print legibly Authorized Signatures: Manager must be authorized signer for GL above ___________________________________________________________________________ Cardholder’s Signature Print Name Date Manager’s Signature Print Name Date Additional Signature Print Name Date (as required for GL or Dollar Amount) To be completed by Business Office: Date received ____________ Approved Declined Request No _________ Reviewed by ______________ Card Ordered __________ Card Received _________