Gift Card/Certificate Request Form
(pre-approval required)
Vendor Information:
Vendor Name: __________________________________________ Type (brand ) of Gift Card:_________________________
Address of Purchase: ___________________________________________________________________________________
Gift Gard Information:
Value of Gift Card/Certificate:______________ (each ) Number of Gift Cards/Certificates:_______________
Purchase Card Information:
Cardholder Name_____________________________________ Last 4 digits of Card: _______________
Activity/Event Information:
Name of Event: ______________________________________________________________________________________
Date of Event:_____________________________ Location: __________________________________________________
Participants: (e.g. students, faculty/staff/guests, etc.)________________________________________________________
# of Attendees/Participats:_____________________________________________________________________________
*
Student Prize Form must be attached to and scanned with paid receipt and any other applicable documentation
Purpose/Justification:_________________________________________________________________________________
___________________________________________________________________________________________________
Approvals:
Cardholder Signature: ____________________________________________________ Date______________
Supervisor/Budget Manager Approval:_______________________________________ Date _____________
Agency PCard Coordinator Signature:________________________________________ Date _____________
WV State Auditor’s Office, PCard Division:
Approved:_______________________________ Denied:_________________________________ Date_______________
___________________________________________may utilize the PCard for the request to purchase gift cards as outlined on
this document as long as your institution can provide documentation of its authority for this type of expenditure, if requested;
and all applicable laws, rules and regulations, purchasing policies, and other governing instruments are adhered to. Please also
keep a record of the recipients name and contact information who receives the card as well as the normally required PCard
documentation.
October 2015
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