Mercer University School of Medicine
Pcard Authorization Form
Cardholder Name
*
Pcard #
*
(Last 4 digits only)
Cardholders Email
*
example@example.com
Campus
*
Please Select
Columbus
Macon
Savannah
Valdosta
Date
*
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Department
*
Vendor
*
Deliver To
*
Phone
Vendors Phone Number
Format: (000) 000-0000.
Contact
*
Mercer Employee
Website
Vendors website
Phone
*
Contact Persons Phone Number
Format: (000) 000-0000.
ITEMS TO BE ORDERED
*
Subtotal (Please enter total from line 11)
*
SALES TAX
Shipping Charges
TOTAL
Purpose of Purchase (Required for Approval):
*
Funding Source
*
NOTE
:
Please provide a list of attendees if food is purchased for a meeting, event, or group lunch.
List of Attendees
Relationship to MUSM (Place an "X" in box unless external relationship)
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