GIFT CARD/CERTIFICATE
ACCEPTANCE AGREEMENT
This form must be completed by each recipient of a gift card/certificate. This completed Acceptance
Agreement should be maintained by the department with the Gift Card/Certificate Disbursement Log
and Authorization Form. A copy of this completed form must be submitted to Accounts Payable.
1. Recipient’s Name (Please Print): _____________________________________________________
2. Mailing Address: _________________________________________________________________
3. City, State, Zip: __________________________________________________________________
4. Telephone/Mobile Number: _________________________________________________________
5. Email Address: ___________________________________________________________________
6. University Employee or Student ID# __________________________________________________
7. Non-Employee or Non-Student’s Last Four Digits of Social Security Number: __________________
8. Are you an Employee for the University of Maine System? _________________________________
9. Are you a Nonresident Alien? _______________
10. Description of Gift Card/Certificate Received: ___________________________________________
11. Face Value of Gift Card/Certificate Received: $ _________________________________________
Please note:
If you are a University of Maine System employee or student, the value of your gift card/certificate is
taxable income under IRS regulations.
I understand and agree to these terms and conditions.
Recipient’s Signature: _____________________________________________________________
Date: __________________________________________________________________________