NOTICATION OF TRAVEL CARD/ CBA
DISCREPANCY/ VIOLATION 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
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 P-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 PROGRAM ADMINISTRATOR USE ONLY:
| MATTER ADDRESSED with cardholder and supervisor/budget head. On file for 12 months.
|
REFERRED TO HUMAN RESOURCES FOR INVESTIGATION due to nature of or number of discrepancy/violation(s).
_________________________________________________ _________________________
CBA Administrator’s Signature Date
Form 3300/018 (8/18)
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