BruinCard MealCourtesy Coupons Order Form by byr88615


									                                      BruinCard Meal/Courtesy Coupons
                                                Order Form
Contact Information
                                                                                              Ucl a
Please print legibly:
                                                                                              BRUIN            CARD
Contact person:
Phone Number                                                              Email
-OR- Extension:                                                          Address:

Card Information
Please check one:                 On-Campus Food Eateries Only                All locations where BruinCard is accepted
Name on card         (maximum
of 20 characters):

Number of cards:                                                  Amount per Card: $

Activation Date:                                                    Expiration Date:

Name of authorized person to pick up card:
Department Head's Approval (Print
Name and Signature):

UCLA department must indicate the proposed use of the meal cards:

                                Loc    Account              CC         Fund            Proj       Sub | Ob      Source

       UCLA FAU:                                                                                      |

                                Authorized signatory on FAU:

                                Print Name:

                                Email Address:
       Check (Payable to “UC Regents”)
Please mail or deliver original order form to BruinCard Center, 123 Kerckhoff Hall, Mailcode: 166906. A
confirmation will be emailed to you within 3 business days of receipt of order form. For a complete listing
where the BruinCard is accepted, please visit our on-line card office at Questions?
Contact the BruinCard Center at extension 52336 or email

POLICY: Balances will remain on limited - use cards until card expiration date. Positive balances that remain on
limited - use cards that have expired will revert to the University. Expired cards containing funds initially recharged from
a department account (FAU) will be credited back to said account 30 days after the expiration date to ensure all
transactions have been cleared AND upon the return of the expired cards to the BruinCard Center.

BruinCard Staff USE ONLY
Manager's Approval/Date:
ID Range Assigned

Total value on card(s):                $                                      Administrative Fee $
Cards Picked up by (Print

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