1. 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 _________