The University of Memphis
Departmental Copy Card
Return form to: Campus Card Office
115 Wilder Tower, Memphis, TN 38152
Fax: (901) 678-0716
TO BE COMPLETED BY DEPARTMENT
 
INDEX FUND ORGN ACCT PROG ACTV
Enter Number of New Card(s) Note: $1 will be deducted from amount deposited on new card(s)
# of new cards
$ Amount on card
# of new cards
$ Amount on card
# of new cards
$ Amount on card
Total # of cards
TOTAL $ amount to charge department
Reload Current Copy Card(s)
Reload Card #
$ Amount on card
Reload Card #
$ Amount on card
Reload Card #
$ Amount on card
TOTAL $ amount to charge department for reloaded cards
Additional Instructions/Comments:
DEPARTMENTAL APPROVAL INFORMATION

Requested By

Date

E-mail Address

Phone
________________________________________________
Department Head Signature
____________________
Date
OFFICE USE ONLY
Card # Range:___________________ - ___________________ $ Amount Each Card:________________________________
Campus Card Office Signature: _____________________________________ Date:___________________
Bursar's Office Signature: _____________________________________ Date:___________________ JV#:___________________
CARDS RECEIVED BY
Signature: _____________________________________ Date:___________________
The University of Memphis, one of the Tennessee Board of Regents institutions, is an Equal Opportunity/Affirmative Action University.