NOTICATION OF PURCHASING CARD

DISCREPANCY/ VIOLATION FORM

               Today’s Date:  

Cardholder’s Name:

Purchasing Card Account #:

Supervisor/Budget Head’s Name:

Form Initiated By (Check one):

 CARDHOLDER  SUPERVISOR/BUDGET HEAD    PURCHASING CARD                      ADMINISTRATOR

Date(s) of Discrepancy/Violation:

Describe Discrepancy/Violation: - (Give date(s), details and describe nature of the discrepancy or violation (i.e., policy/procedure violation, card misuse, card abuse, as per Purchasing Card policy)

Describe/Explain Circumstances Causing Violation/Discrepancy: (Describe purchases, vendors, amounts, individuals involved, etc., as applicable. Attach supporting documentation, if necessary.)

Description/Dates of Previous Discrepancy/Violations for Card Account in the last 12 months:

_________________________________  __________________________________  _______________

Signature        Print Name        Date

SUBMIT FORM TO PURCHASING CARD ADMINSTRATOR

FOR PURCHASING CARD ADMINISTRATOR USE ONLY:

  MATTER ADDRESSED with cardholder and supervisor/budget head. On file for 12 months.  

  REFERRED TO REVIEW COMMITTEE due to nature of or number of discrepancy/violation(s).

 REFERRED TO HUMAN RESOURCES FOR INVESTIGATION due to nature of or number of  discrepancy/violation(s).

_________________________________________________    _________________________

Purchasing Card Administrator’s Signature      Date

Form 3300/015 (12/09)

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