Western Kentucky University
Cellular Phone/PDA Allowance Request Form
Employee Information
Name:
Title:
WKU ID Number:
Cellular Number:
Allowance Information
Department:
Banner Index Number:
Monthly Allowance Amount:
Cellular Voice/Text Plan.....................................$30 per month
Data Plan ................................................................... $20 per month
Cellular Voice/ Text/Data Plan……………….. $60 per month
Employee Signature
I certify that I have read, understand, and intend to comply with WKU’s “Policy and Procedures for Cellular Telephones and Personal Digital
Assistants (PDA).” I further certify that I understand that the allowance amount shown above will be added to my paycheck on a monthly basis,
that it does not represent an increase in my base pay and that the amount of the allowance will be included on my year-end W2. I agree to
maintain an active cellular contract for the life of the allowance.
Employee Signature
Date
Supervisor Signature
I certify that the requested allowance is needed by the employee for business related purposes. I acknowledge that the amount of the allowance
will be taken from the operating budget listed above, and that I have the authority to approve such a budget request. I agree to review the need
for this allowance at least annually. I agree to maintain this record in departmental files for the duration of allowance.
Supervisor Signature
Date
Comments: (List reasoning for the cellular allowance.)
Note: This form is not used for official assignment of cellular allowance. An EPAF must be completed and submitted for the cellular allowance to
take effect. This form is for your department records only.
ver.9.23.2013