The information on this form is personal information and must be protected under the provisions of FOIPP.

INSTRUCTIONS

·  iCards with Microfiche/Pay For Printing authorization must be used in accordance with established budget allowances and practices; and in accordance with the iCard cardholder agreement.

·  Please allow two (2) weeks for processing.

·  Forward the completed form with authorizing signature to the iCard office (Room 1008).

PERSONAL iCard

·  Provide authorization for an employee to place department / program cluster charges with the use of a Microfiche/Pay For Printing copier on a personal iCard for payment by the department / program cluster.

·  Each personal iCard can only have one budget code assigned to it due to system requirements

ADD / REMOVE / EMPLOYEE NAME / ID NUMBER /

DEPARTMENT /

PROGRAM CLUSTER

/ BUDGET CODE
FUND / ORG / ACCT / PROG
110111021112112111221123112411415401810181058106810781098111 / 7215 / 009911011201131116012001291230013911391241014202500170017801901198119841984398479855
110111021112112111221123112411415401810181058106810781098111 / 7215 / 009911011201131116012001291230013911391241014202500170017801901198119841984398479855
110111021112112111221123112411415401810181058106810781098111 / 7215 / 009911011201131116012001291230013911391241014202500170017801901198119841984398479855
110111021112112111221123112411415401810181058106810781098111 / 7215 / 009911011201131116012001291230013911391241014202500170017801901198119841984398479855
110111021112112111221123112411415401810181058106810781098111 / 7215 / 009911011201131116012001291230013911391241014202500170017801901198119841984398479855
110111021112112111221123112411415401810181058106810781098111 / 7215 / 009911011201131116012001291230013911391241014202500170017801901198119841984398479855
110111021112112111221123112411415401810181058106810781098111 / 7215 / 009911011201131116012001291230013911391241014202500170017801901198119841984398479855
110111021112112111221123112411415401810181058106810781098111 / 7215 / 009911011201131116012001291230013911391241014202500170017801901198119841984398479855
DEPARTMENT/ PROGRAM CLUSTER ICARD

·  Provide authorization for employees to place department / program cluster charges with the use of a Microfiche/Pay For Printing department / program cluster copy iCard for payment by the department / program cluster.

·  Department / program cluster copy iCards will accommodate individuals with multiple code charging privileges.

·  Each department / program cluster copy iCard can have only one budget code assigned to it due to system requirements.

ADD / REMOVE / DEPARTMENT / PROGRAM CLUSTER /

# OF CARDS

/ BUDGET CODE
FUND / ORG / ACCT / PROG
123456789101112131415161718192021222324 / 110111021112112111221123112411415401810181058106810781098111 / 7215 / 009911011201131116012001291230013911391241014202500170017801901198119841984398479855
123456789101112131415161718192021222324 / 110111021112112111221123112411415401810181058106810781098111 / 7215 / 009911011201131116012001291230013911391241014202500170017801901198119841984398479855
123456789101112131415161718192021222324 / 110111021112112111221123112411415401810181058106810781098111 / 7215 / 009911011201131116012001291230013911391241014202500170017801901198119841984398479855
123456789101112131415161718192021222324 / 110111021112112111221123112411415401810181058106810781098111 / 7215 / 009911011201131116012001291230013911391241014202500170017801901198119841984398479855
123456789101112131415161718192021222324 / 110111021112112111221123112411415401810181058106810781098111 / 7215 / 009911011201131116012001291230013911391241014202500170017801901198119841984398479855
123456789101112131415161718192021222324 / 110111021112112111221123112411415401810181058106810781098111 / 7215 / 009911011201131116012001291230013911391241014202500170017801901198119841984398479855
123456789101112131415161718192021222324 / 110111021112112111221123112411415401810181058106810781098111 / 7215 / 009911011201131116012001291230013911391241014202500170017801901198119841984398479855
123456789101112131415161718192021222324 / 110111021112112111221123112411415401810181058106810781098111 / 7215 / 009911011201131116012001291230013911391241014202500170017801901198119841984398479855
AUTHORIZATION
NAME / SIGNATURE / DATE
REMEMBER TO CARRY YOUR iCard

03/09