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					                                       Wireless Phone Allowance Request or Cancellation Form
                                                                  East Tennessee State University
                                                                     Johnson City, Tennessee


Please complete all fields below to request an allowance for wireless telephone or data service in conjuction with ETSU's Cell
Phone Policy. Please return completed form to: Payroll Office, P.O. Box 70732. Forms received in the Payroll Office by the
15th of the month will be included in the upcoming payroll.

Name (Last, First, MI)                                                                        Employee ID

Date                                            Phone No.                             P.O. Box

Department                                                   Index Number                               Account Code



                         New                    Renewal                  Change                  Cancellation
Rate Options (Please choose one.)
        Basic             Minutes                 Amount
                         450                       $41.00
                         900                       $61.00
                         1350                      $81.00
PDA/Smartphone            Minutes
                         450                        $91.00
                         900                       $111.00
                         1350                      $119.00

                                                                                   Total Monthly Service Allowance           $0.00

I have read the terms of ETSU's Cell Phone Policy and understand the employee responsibilities as outlined. I understand that
the allowance provided by the University for wireless telephone or data service is taxable income and is NOT part of my base
salary and that contract provisions of any wireless service plan entered into under this program are my personal responsibility. I
also certify that the wireless service will be used in the performance of my job responsibilities at East Tennessee State
University, as defined by my supervisor. I will provide my cell phone number to my supervisor within five days of activation and
will be available for calls during times specified by my supervisor.
I am responsible for the payment of any cost that exceeds the approved University allowance. If I cancel or reduce my cell
phone contract below the allowance amount during the year, I must complete a new form to notify my department and the
Payroll Office to stop or reduce the allowance. If my cell phone service is cancelled or reduced below the allowance level, I am
responsible for repayment to ETSU for the amount of allowance overpayment from the date of cancellation or reduction and
authorize a payroll deduction for such overpayment. When I terminate employment, the cell phone allowance will be stopped
and will not be included in any terminal payroll payout.


Employee Signature                                                                               Date

APPROVED:


Supervisor's Signature                                                                           Date



Department Head Signature (required)                                                             Date



Vice President Signature (required)                                                              Date




  Received in Payroll Office
  Payroll will forward to the Budget Office for appropriate budget transfers.

Rev. 6-08

				
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