Alabama A&M Unviersity
Normal, AL 35762
GAS CARD AND PIN ASSIGNMENT
Department: ______________________ Telephone Number: ______________ Date: ____________
By signing this form, you will be held responsible for the gas card in your possession as well as a pin
number issued to you and all charges made associated with that pin. If a card is lost or misplaced,
notify the Department of Physical Facilities immediately at extension 8419, as you will be responsible
for all charges against the card until it is cancelled. Gas cards and pin numbers are for University
employees only and will not be issued to undergraduate or graduate students. You will also be
responsible for submitting gas receipts for the billing period for gas that was purchased between the
23
rd
of the previous month to the 23
rd
of the current month (ex. January 23
rd
- February 23
rd
) and
should be submitted via email to vindetta.medlock@aamu.edu by the end of each current month to
avoid the deactivation of gas card service.
Number of University Vehicles (one card per university vehicle): _________
Is a gas card needed? _____ Yes ____ No If yes, how many? ________
Vehicle Make, Model, Year
Number of Drivers (PIN numbers will be issued to each individual driver): __________
ACCOUNT INFORMATION – Please provide the accounting information for all gas cards charges
FUND ___________ ORGANIZATION ____________ ACCOUNT _________ PROGRAM ____________
____________________________ _______________________________________
Department Head Department Head Signature Date
____________________________ ________________________________________
Facilities Coordinator Facilities Coordinator Signature Date
