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FUEL CARD/PIN # DEPARTMENT ORDER FORM

 

U of L Departments:  Complete the following form to order your fuel card, and for adding or deleting a pin number.  Order form will be submitted electronically to Alma Brandon.  Once received, Purchasing will review and forward order to Comdata.  You will be contacted by Purchasing for your card pickup.
 

CARD ORDER SECTION

 

Complete this section to order your fuel card.  For new cards you will also need to complete the Pin Order Section below as well.

 

LINE # CUSTOMER
    ID #		 CARD INFO
(Please select
one)		 DEPARTMENT
NAME:
 		 COMPANY NAME : LICENSE PLATE
NUMBER:
IF PHYSICAL PLANT LIST SUB DEPT. NAME:
(Max 15 spaces)		 PHYSICAL PLANT CHOOSE UNIT. 
ALL OTHER DEPARTMENTS CHOOSE PLATE.		 COMPANY  PROFILE #
(Please select one)		 VEHICLE DESCRIPTION -
PHYSICAL PLANT WILL ENTER N/A		 SPEEDTYPE TO BE CHARGED
1   U of L
2   U of L
3   U of L
4   U of L
5   U of L

 

PIN NUMBER ORDER SECTION

 

This section needs to be completed to order or delete an existing Pin Number.  When ordering a Pin Number always reference the Line # listed in the Card Order Section.  When deleting a Pin Number reference the Customer ID Number for the existing card.

 
LINE # THAT PIN NUMBER IS BEING ORDERED OR
CUST. ID NUMBER FOR EXISTING CARD		 PIN # INFO
(Please select one)		 NAME OF INDIVIDUAL DEPARTMENT NAME ADDING PIN NUMBER (YES OR NO) DELETING PIN NUMBER (YES OR NO) NAME OF DEPARTMENT CONTACT THE PIN NUMBER IS TO BE SENT CONTACT PHONE NO. EMAIL ADDRESS OF DEPARTMENT CONTACT THE PIN NUMBER IS TO BE SENT

 

Name of Person Completing Form:
Name: UserID: Date: