1.        
    1. TRAVEL CARD/CBA
    2. UNAUTHORIZED PURCHASE FORM
      1.            
      2.      
    3.         Today’s Date: 
      1. Cardholder’s Name:
      2. Travel Card/CBA #:
      3. Supervisor/Budget Head’s Name:
      4. Form Initiated By (Check one):
      5.  CARDHOLDER SUPERVISOR/BUDGET HEAD   CBA             ADMINISTRATOR
    4. Description/Amount/Date of Unauthorized Purchase:
      1. How Will Purchase Be Reimbursed to the College? Check one:
      2.  APPLICABLE RESTOCKING OR RELATED FEES.
      3.  ___________________________________________   _______________
      4.  Signature of Cardholder      Date
      5.    ___________________________________________   _______________
      6.  Signature of Approver      Date
      7.  ___________________________________________   _______________
      8.  Signature of Supervisor/Budget Head (if different than Approver) Date



       



TRAVEL CARD/CBA



UNAUTHORIZED PURCHASE FORM



                     



         



               Today’s Date:  



Cardholder’s Name:



Travel Card/CBA #:



Supervisor/Budget Head’s Name:
 



Form Initiated By (Check one):



 CARDHOLDER  SUPERVISOR/BUDGET HEAD    CBA                          ADMINISTRATOR
 



Description/Amount/Date of Unauthorized Purchase:


 
 
 
 
Explanation for Unauthorized Purchase: Provide circumstances causing unauthorized purchase. Add an additional sheet and/or supporting documentation, if necessary.


 
 
 
 



How Will Purchase Be Reimbursed to the College? Check one:
 

  CARDHOLDER WILL RETURN MERCHANDISE AND PERSONALLY PAY FOR ANY



 APPLICABLE RESTOCKING OR RELATED FEES.
 

  CARDHOLDER WILL PAY BY CHECK OR MONEY ORDER TO CONTROLLER’S OFFICE   PRIOR  SECOND PAYDAY AFTER UNAUTHORIZED PURCHASE WAS NOTED.
 


___________________________________________      _______________



 Signature of Cardholder            Date




    ___________________________________________      _______________



 Signature of Approver            Date
 


___________________________________________      _______________



 Signature of Supervisor/Budget Head (if different than Approver)  Date
 

Original to CBA Administrator; Copies to Cardholder, Approver, and Supervisor/Budget Head

Form 3300/017 (8/18)

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