AUTHORIZATION FOR PURCHASE ON CAMPUS
DEPARTMENT CREDIT CARD

                      **ONE TRANSACTION USE ONLY**

(Please Print)

Date                                                   

Name of Cardholder                                                                  

Credit Card Number                                                                       Exp. Date                                         

Cardholder's / Department Phone Number                                                   

Description of Items:

Cost Not to Exceed:                                        

User's Name                                                                   Student/Faculty ID Number                                       

User's Signature                                                                        

Cardholder's Signature                                                                                  

REQUEST WILL ONLY BE PROCESSED WITH SIGNATURES AND DESCRIPTIONS OF ITEMS
BEING PURCHASED.

** USER NEEDS TO SHOW PHOTO ID **