ALABAMA A&M UNIVERSITY
GAS CARD AND PIN ASSIGNMENT
Department:________________________
Number of University Vehicles (one card per university vehicle):_________
Vehicle Make, Model, Year
VIN Number, State Tag
Number of Drivers (PIN’s will be issued to each driver) :___________
Driver’s Name
Driver’s Signature
By signing this form, you will be responsible for the gas card in your possession as well as pin number
issued to you and all charges made associated with that pin. If a card is lost or misplaced, notify the
Department of Facilities immediately at extension 5829 as you will be responsible for all charges against
the card until it is cancelled.
ACCOUNT INFORMATION- Please provide accounting information for all gas cards charges
FUND__________ ORGANIZATION____________ ACCOUNT__________ PROGRAM_____________
__________________________
______________________________________
Department Head Name
Department Head Signature
__________________________
________________________________________
Vice President Signature
Vice President Signature
Date
Date