Mobile Communications Agreement and Reimbursement Request Form
Name: Job Title:
Department:
Mobile Device Provider
& Full Account Number:
Mobile Phone
Number for Request
:
Reimbursement Start Date:
Justification:
End Date:
(Up to one year from start date)
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_______________________________ __________ _____________________________ ____________
Check only one box next to the reimbursement service requested (level of reimbursement will be
determined by supervisor based on job title/level/requirements):
Level I - Chancellor, Vice Chancellors, CIO, Executive Directors, Campus/Site Coordinators, exceptions
approved by the Chancellor - Up to $ ___.00 per month
Level II - Deans, Directors if meet criteria in Section B as determined by supervisor, and other employees
required to be available 24/7 to an extent that is consistent with these Level II job titles - Up to
$___.00 per month
I certify that:
I understand that to receive reimbursements, I am required to be reachable by means of mobile or electronic
messaging device at all times when: 1) SOWELA management needs to contact me at all times 24/7 or for
emergencies, 2) SOWELA management and college personnel need to reach me when away from the office during
working hours and, 3) College or State personnel need to reach me outside of working hours;
I have attached a copy of my personal mobile communications service plan for which I am requesting future
reimbursement, and I certify that the mobile or electronic messaging device is in my name and I am solely
responsible for complying with any contract entered into with the service provider including but not limited to the
payment of all expenses incurred (long distance, roaming fees, taxes, penalties, etc.);
I have read and agree to the College’s Mobile/Electronic Messaging Device Policy; I understand I must also adhere to
the requirements of the College’s Information Technology Acceptable Use Policy #7.001.1 while using the personal mobile
or electronic messaging device when performing official business;
I understand that the above reimbursement will be used toward expenses I incur for mobile/electronic messaging device
usage while conducting official business for the College;
I understand that the monthly reimbursement must not exceed the expenses in maintaining the appropriate service plan;
I know I am responsible for immediately notifying the Controller’s Office regarding any changes to my plan that would
affect reimbursement, and if the service plan changes and the reimbursement amount exceeds the service plan, I must
return the excess funds within 90 days; and
I understand that access to the College’s electronic resources is a privilege and not a right; therefore, I further understand
that the College has the right to require security products to be placed on my personal device in order to protect College
assets.
Employee's Signature Date Supervisor’s Signature Date
Approval:
Approved Monthly
______________________________________ ____________ Reimbursement (if applicable):
Controller Date
For Office Use:
Copies: Employee, Supervisor; Original: Controller’s Office Form: RMB 1001
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