STATE OF NEW JERSEY
DEPARTMENT OF THE TREASURY
DIVISION OF ADMINISTRATION - TRANSPORTATION SERVICES
REQUEST FOR CREDIT CARD ASSIGNMENT
Note: The purpose of a retail credit card is to provide a supplemental means of obtaining motor fuels and
essential fluids, and to effect minor repairs for the named supplier in emergency situations.
1. Department
2. Division
3. License Plate:
4. Type of Assignment (Check one)
A.
Individual Assignment:
Name
Official Work Station
Home Address
B.
Pool Assignment:
Name of office or organizational unit
Address where vehicle will be parked when not is use
C.
Out-of-state use:
Destination:
Dates: Begin
Return
Request for temporary assignment of out-of-state card
Request to use assigned card
JUSTIFICATION:
5. I certify that all the information supplied on this form is true to the best of my knowledge. I have read and understand the
conditions pertaining to the assignment and use of credit cards on the reverse side of this form.
Signature of assignee:
Office Phone #:
6. Department/Agency Approval:
Signature of Department/Agency Head:
Office Phone #:
7. Department of Treasury, Division of Administration Approval:
Approved
Denied
Signature of Supervisor, Vehicle Administration:
This space for use by Transportation Services only.
1
st
issue credit card #
Issued to vehicle license #
2
nd
issue card#
Comments
Temporary card#
By
Date:
ADMV-106 rev 6/2009
Limitations:
The purchase of “high-octane” or other premium priced motor fuel is strictly prohibited
, unless required by the OEM and
approved by Fleet Management on this form.
Credit cards are to be used only
when State operated fueling or repair facilities are not available, or in an actual
emergency situation. Emergency situations must be reported to Transportation Services as soon as possible after each
occurrence.
Credit usage for repair service is limited to one hundred dollars
($100.00). Repairs exceeding $100.00 must have prior
authorization from the Assistant Supervisor, Central Motor Pool Operations; (609) 984-4323.
Credit card usage is limited to the named contract supplier
on the card. Credit cards should not be used at any other
service stations-regardless of the willingness of other vendors to accept the card. Any other charges incurred are the
direct responsibility of the driver or the agency.
Credit cards are vehicle specific; they are not transferable.
Credit cards assigned to vehicles no longer in service must be returned to Transportation Services, Fleet Management, 605
South Broad Street, Trenton, NJ 08625-0233.
Sales Receipts
must contain the following information:
1. Price per gallon 4. Signature of driver
2. Number of gallons sold 5. License plate of vehicle written on receipt (Embossed license number
3. Quarts and price of oil from card does not suffice).
Lost or stolen credit cards
:
1. Must be reported immediately to Transportation Services, Fleet Management (609) 984-5272.
2. Credit cards will only be replaced once per vehicle, per contract.
Out-of-state use:
An ADMV-106 must be submitted to: Supervisor, Vehicle Administration, Department of the Treasury, Division
of Administration, PO Box 211, 50 West State Street, 8
th
Floor, Trenton, NJ 08625-0211, for each trip, for either:
Permission to use the existing card, or
Assignment of a Temporary Out-of-state card.
Out of state use is defined as travel twenty-five (25) miles or more beyond the state border.
Negligent use of credit cards
(including charges made against lost or stolen cards that were not reported as explained
above, or the purchase of premium fuel, non-essential fluids, for convenience, or non-emergency repairs) will result in
direct charge backs to the agency or department, and possible forfeiture of the credit card.
Abuse of credit cards
will result in immediate forfeiture of the card, automatic denial of future requests for credit cards,
and disciplinary action.