APRIL 2009

Montgomery County Public Schools

Department of Materials Management
Division of Procurement
850 Hungerford Drive, Suite 162
Rockville, MD 20850
301-279-3555

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Executive Summary

The major changes to the Purchasing Card User’s Guide are listed below.

a) The purchasing card is the preferred procurement method for purchases that are less than
$50.
b) Assistant Program Administrator has been changed to Program Card Administrator, and
the duties have been defined in additional detail.
c) All cardholders are still required to complete log sheets. The Purchasing Card Member
Transaction Log, Montgomery County Public Schools (MCPS) Form 234-21, has been
updated to include a block identifying the expenditure as being for students or for other
purposes. It must be filled out completely.
d) Furniture purchases are prohibited.
e) Gift card purchases are prohibited.
f) Improper card charges will require reimbursement to the Division of Controller.
g) Those card members with travel authority will sign a modified card agreement and must
agree to comply with applicable MCPS travel policies.
h) Principals and directors will forward log sheets to community superintendents and
associate superintendents.

1.0 Purpose, Exclusions, and Definitions

Purpose

The MCPS Purchasing Card Program has been established to streamline the process for
making low-dollar purchases that are necessary for MCPS operations. It is the preferred
method of procurement for all small purchases not on a bid list and less than $50 (also
referred to as micro purchases). Principals are authorized to use the purchasing card
(only IAF) for clothing or assistance for needy students, as outlined in the IAF Manual.
These disbursements will require written authorization from the Office of School
Performance.

Use of the purchasing card does not relieve the card member from complying with the
MCPS Procurement Manual, IAF Manual, and all MCPS regulations, especially the
requirements in MCPS Regulation DJA-RA, Procurement of Equipment, Supplies, and
Contractual Services.

Examples of permitted items include the following:

• Approved materials of instruction

• Books, periodicals, and newspapers
• Art supplies, glue sticks, and crayons
• Grocery items within documented limitations
• Sheet music
• Office supplies
• Computer cables and flash drives

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 • Audio/visual aids for students
• Stationery, such as specialized paper and pens and pencils
• School supplies, such as dry erase markers, paper towels, facial tissues, and band aids
• Clothing for needy students within documented limitations
• Storage containers for classrooms
• Approved software
• Landscaping items, such as bulbs, small trees, and supplies

Exclusions

The materials and services listed below shall be excluded from the Purchasing Card Program.

a) Transactions greater than standard dollar limits.

b) Travel and entertainment expenses, including, restaurants, common carriers, and
accommodations.
c) Furniture.
d) Gas and oil, including car rental.
e) Disbursements that are primarily for the benefit of school staff members or other MCPS
employees, such as gifts, meals, retirement functions, or other staff social activities.
f) Transactions resulting in “insufficient funds.”
g) Cash access and gift cards.
h) Amusement and entertainment (e.g., movie theaters, bowling alleys, video game
clubs, and recreation services).
i) Any disbursement that is prohibited by federal, state, or county law, or by MCPS
policy or regulation.

Any questions regarding exclusions should be directed to your supervisor for

clarification. Those card members that have been given authorization to use the
purchasing card for travel and restaurants will be given additional instructions under
separate cover, including the requirement to sign a different purchasing card agreement
(included at the end of this guide). In all instances, current MCPS travel and
procurement policies and regulations must be followed.

Definitions

Approving Official
The approving official for school-based personnel is the principal. For central office, the
approving official is a director or coordinator. This is the person in authority who will be
responsible for card activities of subordinate card members.

Card Member
The card member is the employee to whom the card is issued. The card bears the
employee’s name and may only be used by that employee to make authorized purchases
for MCPS. Card members are reminded to safeguard their cards with appropriate
security measures in accordance with good business practices.

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 Program Administrator
The program administrator (director, Division of Procurement) serves as the liaison for
the school system with the card member and is the contract administrator. This involves
quality control and testing, specific contract delivery requirements, special contract
provisions, and MCPS procedures for monitoring and measuring performance. He/she
will set the spending amount per transaction, billing cycle, and month that will limit card
member transactions to a predetermined dollar amount within any defined period. In
addition, the Division of Procurement will set up and define Merchant Category Codes
(MCC). The MCC is a 4-digit code assigned by the supplier’s credit card processor
according to category or type of business a merchant conducts from which MCPS staff
may purchase.

Program Card Administrator

The program card administrator (controller, Division of Controller) serves as back-up to
the program administrator in contract administration. He/she serves as point-of-contact
for the Purchasing Card Program’s initial account set-up and ongoing account
management. Account management includes processing of spending limits or transaction
increases (permanent and temporary), issuance of new cards, reporting of stolen or lost
cards, and answering general questions as needed.

Purchasing Card Provider—(currently American Express)

Purchasing cards benefit MCPS by expediting payment and reducing paperwork

associated with purchase orders and invoices for small dollar transactions. The provider
supplies MCPS with detailed reports and allows staff to acquire small dollar goods
without subjecting vendors to payment delays.

2.0 Roles and Responsibilities

The Card Member

a) Acknowledges that the purchasing card is the property of MCPS and should
only be used for official business purposes.
b) Accepts responsibilities under the MCPS Purchasing Card Program and
agrees to comply with the requirements set forth in this User’s Guide and all
MCPS policies and regulations by signing the MCPS Purchasing Card
Agreement.
c) Does not give the card number to any other individual, even to place orders
with a supplier. The purchasing card is a charge card and must be used in
such a manner that ensures its security and safekeeping. The purchasing
card is non-transferable. Allowing anyone else to use the card will result in
termination of card privileges. The card member must be the person placing
the order with the supplier.

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 d) Notifies card provider immediately of a lost or stolen purchasing card and
advises his/her approving official and the program card administrator.
Notification is required to release MCPS from liability for charges incurred
by someone other than the card member.
e) Advises the supplier at the time of transaction of the following:
1. The shipping address, including the name and phone number, of the
person to whom the material is to be delivered.
2. The MCPS school, office, division, or department that is placing the
order at the time of purchase or requisition.
3. The tax-exempt status of MCPS (i.e., no sales tax). The tax exemption
number is listed on the card.
f) Obtains a receipt and/or a packing list at the point of receiving purchases
and verifies that the materials and/or services received are in the quantity
ordered, in good condition, and the correct items ordered.
g) Treats returns and credits of goods as separate transactions. They are not to
be handled as exchanges or combined with other purchases, and the account
holder may not accept cash refunds.
h) Reviews statements each month for accuracy and gives statements with logs
and invoices/receipts to the approving official to be retained by the
approving official for future reference and audit. (Click here to review,
MCPS Form 234-21, Purchasing Card: Card Member Transaction Log.)
1. Notifies a card provider customer service representative of any billing
discrepancies posted on the Monthly Reconciliation Statement that cannot
be resolved with the supplier. The card provider will place these charges in
dispute until they are resolved.
j) Contacts the program administrator (or program card administrator) for
assistance in informing suppliers who are not currently purchasing card
suppliers of the advantage of accepting the purchasing card from MCPS.
MCPS Division of Procurement website—Procurement@mcpsmd.org.

Approving Official (Principals, Directors, Coordinators)

a) In collaboration with the program administrator, establishes appropriate

guidelines and procedures for use of the purchasing card at the school and/or
office level consistent with the requirements set forth in this guide and
MCPS policies and procedures, including setting transaction and monthly
limits for each subordinate card member.
b) Reviews and signs the monthly summary report within 14 calendar days of
receipt. Signature indicates that the approving official has reviewed all
monthly transactions to ensure purchases are made in accordance with
MCPS policies and regulations.
c) Approves and retains all documentation, including card members’ monthly
statements and transaction logs, for a period of five fiscal years for future
reference and audit.

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 d) Ensures subject records are complete and turns over all records to successor
principal, director, or coordinator upon reassignment or retirement.

Program Administrator and Program Card Administrator

a) Develops and coordinates training for card members and approving officials
and provides updates to card members.
b) Works with card members to identify new suppliers/merchants.
c) In collaboration with approving officials, establishes and maintains card
member records and controls regarding transaction limits, monthly limits,
reporting hierarchy, and card expiration date.
d) Coordinates card member enrollment, termination, and changes. (Click here
to review MCPS Form 234-20, Purchasing Card File Maintenance
Worksheet).
e) Identifies program improvements and enhancements for new purchase
agreements. This may include negotiation of discounts on future purchasing
card purchases.
f) Serves as point-of-contact for card provider for account set-up and ongoing
account management services.

Division of Controller—Invoice Processing and Remittance

a) Receives and processes monthly purchasing card billing statement to the

MCPS accounting system for payment and input.
b) Performs post-audits of purchasing card transaction activity to ensure proper
functioning of the program.
c) Executes payment of the card provider's monthly billing statement. The
purchasing card billing system is a single bill/central pay arrangement.
Although each individual card member receives a monthly account statement,
payment is centrally executed by MCPS. The grand total of all charges to
MCPS, with supporting detail by card member account, is paid to card
provider within 14 days following the close of the billing cycle.
d) Retains monthly billing statements for five years, as outlined in state
records.
e) Invoices schools for reimbursement of IAF purchasing card expenditures.
Payment is normally expected within 30 days of the invoice.

Merchants/Suppliers

a) Marks boxes and other shipping containers with the proper shipping address
and the card member’s name and telephone number to facilitate identification.
b) Shows detailed information on quantity, description, and price on receipts or
packing lists.
c) Issues paid invoices (as requested by MCPS Department of Transportation
and Division of Maintenance for their special procedures).
d) Segregates individual credit/return transactions. Does not issue cash refunds.

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 e) Maintains the confidentiality of MCPS purchasing card account numbers
and transaction history to prevent this information from unauthorized use.
f) Bills or invoices backorders after shipping.
g) Provides adequate credit card security on supplier’s web page.

Purchasing Card Provider (currently American Express)

a) Processes requests for new purchasing card accounts, changes, or

cancellations of accounts in a timely manner.
b) Sends monthly purchasing card account statements directly to the school,
office, department, or division of individual card members.
c) Resolves billing errors with card members and/or suppliers in a timely manner.
d) Provides a single monthly billing statement to the MCPS Division of
Controller, including all information necessary to apply transaction costs to
the MCPS general ledger code assigned to each purchasing card account.
e) Provides ongoing customer service through MCPS representatives and
program administrator.

3.0 Procedures

Ordering Materials or Services

a) The card member (or his/her approving official) must ensure that funds are
available to pay for items being purchased. This includes items purchased
with a card from IAF.
b) Transactions should not be split in order to exceed single or monthly
purchase limits.
c) All items purchased over the counter must be immediately available. No
back ordering is allowed.
d) All items purchased by telephone should be delivered in a single delivery by
the merchant (supplier) within the 30-day billing cycle. The order should
not be placed without this assurance.
e) Whether by phone or over the counter, the card member shall inform the
supplier that the purchase is for MCPS and is tax exempt. The tax exempt
number is on the card and should be shared with the supplier. The card
member will secure a refund from the supplier or reimburse MCPS for any
sales tax included in the account.
f) Card members shall not be charged for supplies/services until shipped (in
the month for which the supplies/services were ordered).
g) The card member must stipulate that the following is prominently marked
on the outside of all boxes or other shipping containers—shipping address
(including the name and phone number of the person to whom the material
is to be delivered) and the school, office, department, or division for which
the order had been placed.

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 h) If someone other than the card member is picking up the order, the card
member must notify the supplier of the name of this individual and request
that the supplier ask for identification. That person signs for the order being
picked up.
i) The card member transaction log and the monthly statement shall be used to
document purchasing card orders. These logs, with receipts attached, shall
be retained by his/her approving official for at least five fiscal years. These
logs are subject to review by both internal and external auditors. (Click here
to review MCPS Form 234-21, Purchasing Card: Card Member
Transaction Log.)

Returns/Credits

a) The card member is responsible for ensuring that returns of materials to

suppliers are handled as credits and treated as separate transactions. Returns
are not to be handled as exchanges or combined with other purchases. A
separate transaction must be placed to reorder the correct materials.
b) Cash refunds are not allowed under any circumstances.

Picking Up/Receiving Materials

a) Employees who have been authorized by their supervisors to pick up

supplies ordered by a card member must show identification of employment
by MCPS when picking up orders from a vendor. The official MCPS
employment badge is the required identification.
b) The card member verifies that the material received is what was ordered and
verifies the accuracy of all receipts and packing lists.
c) The card member updates his/her transaction log indicating delivery/receipt
of materials ordered.
d) Purchase card transactions are exempt from taxes. MCPS Federal Tax
Identification number is 52-6000989, and exemption is listed on all cards.

Monthly Card Member Statements and Reconciliation

a) The card provider will send monthly account statements directly to the
school/office/department/division of individual card members.
b) Principals will forward a copy of the log with invoice copies to his/her
community superintendent for review and signature. To the greatest extent
possible, electronic signatures and electronic logs will be used to reduce
paperwork and to expedite processing of charges and monthly statements.
Original logs with original invoices will be retained on site for audit
purposes. Only the principal’s log is to be forwarded to the community
superintendent.

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c) Each card member is responsible for checking his/her monthly statement of
purchases or other transactions (e.g., credits). The transaction log (with
attached sales receipts) maintained during the month should be compared
with the monthly statement from the card provider. Part numbers or terms
such as miscellaneous, supplies, office supplies, classroom materials,
general merchandise, or hardware items are not sufficient. The Division of
Maintenance will use a modified method that will be approved in writing by
the chief operating officer.
d) If for some reason the card member does not have documentation of the
transaction to send with the statement, the card member must make a good
faith effort to obtain the required documentation from the merchant. If such
attempts are unsuccessful, the card member must attach an explanation that
includes a description of the item, date of purchase, merchant’s name, and
why there is no supporting documentation.
e) The card member should attempt to resolve any disputed transactions
through the supplier. If a discrepancy cannot be resolved with the supplier,
the card provider should be notified. The card provider (American Express)
will place these charges in dispute until resolved.
f) After review, the card member signs and dates the monthly card member
statement, with transaction log and receipts, and gives it to his/her approving
official within 7 calendar days for retention and audit. The use of a signature
stamp is not acceptable by either the card member or approving official. The
approving official must review the monthly report within 14 calendar days,
including disputed transactions. These timelines must be followed.
g) Below is a graphic representation of the process.

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Procurement MCPS American Express Purchase Card Process

Act on resolving Reviews

authorization monthly
dispute with statement
supplier & end for all sites
user
MCPS End User

Reviews
Payment is Receives monthly Signs
Place order Inform received by individual statement and statement
using P-card Procurement supplier and monthly attaches and sends to
with supplier of rejection PO is statement accountable AP Office
fulfilled documents

Yes
Issues
Validates monthly
and statement
Approved?
authorizes
Amex

for all MCPS

charge sites
Accounts Payable

Receives and
pays American
Reviews
Receives Express
monthly
statement and Invoice
statement for
accountable according to
all sites
documents statement and
accountable
documents

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Lost and/or Stolen Card

a) The card member reports the loss/theft of his/her card (or account number)
immediately to the card provider’s Customer Service at 1-800-492-4920.
b) After the card provider has been contacted, the card member must advise
his/her approving official and the program administrator. Upon notification
to the card provider of a lost or stolen card, further use of the card will be
blocked. Prompt notification of lost or stolen cards (or account
confidentiality) reduces MCPS liability for fraudulent charges.

Issuing a New Card Member Account

a) The approving official completes the card member application and forwards
it to the program administrator to be submitted to the card provider. (Click
here to review MCPS Form 234-22, Purchasing Card: Approving Official
Acknowledgement).
b) The program administrator contacts the potential card member to schedule the
mandatory training session. Cards will be issued at the training session.
c) The program administrator completes applicable sections of the MCPS
Purchasing Card Agreement and obtains the signature of the approving
official for the card member’s participation in the Purchasing Card Program.
d) The card member attends the mandatory training, reads the User Guide, and
is expected to understand his/her responsibilities with regard to the
purchasing card, including the transaction and monthly limits set by his/her
approving official.
e) The card member signs the MCPS Purchasing Card Agreement and gives it to
the program administrator (or his/her representative) at training in order to
receive the MCPS purchasing card.

Cancellations

a) The card member’s approving official must initiate cancellation of the card
member’s account within 48 hours in the event the card member is
transferred to another location or his/her employment is terminated. The
purchasing card accounts cannot be reassigned from one employee to
another. It is a misdemeanor in Maryland, subject to fines and jail time, to
make purchases under $500 with an unauthorized credit card. Making
charges in excess of $500 with an unauthorized credit card is a felony and
subject to longer jail time and larger fines.
b) In the event that the card member’s employment is terminated, the
approving official should expedite cancellation of the card member’s
account by contacting the program administrator immediately.
c) The approving official must collect the card, cut it in half, and retain the
pieces with the financial records when the card member leaves the location.
If the plastic card cannot be collected, the approving official must advise the
program administrator immediately.

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 d) The approving official must provide the program administrator with the
relevant details of the card member's cancellation.
e) The program administrator coordinates cancellation of the card member’s
account with the card provider.
f) The approving official initiates permanent or temporary changes in transaction
or monthly limits to a card member’s account. Upon notification by the
approving official to the program administrator, the program administrator will
complete the necessary form and submit to the card provider.
g) Changes to a card member’s account are normally effective within 48 hours.
h) In emergencies only, the card provider can facilitate change approval
immediately upon notification by the program administrator. In such cases,
the change must immediately be followed by appropriate approval by the
card member’s approving official.

Year-End Procedures

a) All card members shall follow year-end instructions provided by their approving
officials regarding spending limitations as the fiscal year comes to a close.
Information provided by the Division of Controller to approving officials will
include the deadline by which fiscal year-end spending must be completed.
b) All card members who are ten-month employees must turn in their purchasing
cards no later than the same time they relinquish keys and other school
property as the school year closes. However, cards may be requested from
card members earlier at the discretion of the approving officials as spending
limits on cards are reduced to coincide with the end of the fiscal year.

Monitoring and Auditing Purchasing Card Activities

a) The Division of Procurement and the Division of Controller, as well as the

Internal Audit Unit in the Office of Shared Accountability, will conduct
monthly and random audits of purchasing card use. The primary purpose of
these audit reviews is to ensure that the Purchasing Card Program
procedures are being followed and that—
1. purchase volume is reasonable,
2. transactions are appropriate,
3. purchases are properly authorized,
4. split purchases are not being made to circumvent card limits, and
5. documentation is complete.
b) Approving officials are responsible for retaining all receipts and vouchers
for audit by internal and external auditors.
c) In addition to random audits, monitoring of purchasing card use will be
made by the program administrator and the program card administrator
through the use of card provider tools, including online reporting and
program management. Purchasing card activity through card provider tools
also shall be monitored by location by approving officials or their designees.
Areas to be monitored include, but are not limited to, the following:

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 1. Compliance with individual location procurement and purchasing
policies.
2. Compliance with purchasing card procedures.
3. Inappropriate charges of sales and use tax.
4. Inactivity indicates that the need for the card has ended.

d) In general, purchasing card transactions are subject to review by either or

both of the following:

1. Approving official for the activity of the card member

2. Office of Chief Operating Officer

e) If any card is used for an improper purchase, reimbursement will be made to

the Division of Controller. The statement should be annotated to indicate
that an improper purchase was made, identifying the transaction that was
improper. A copy of the annotated statement and a cashier’s check or
money order made out to MCPS should be sent via the Pony to—

Division of Controller
Montgomery County Public Schools
CESC, Room 156
Rockville, Maryland 20850

4.0 Telephone and Contact List

Call the card provider (currently American Express) 24 hours/day,

7 days/week, at 1-800-492-4920. Important reasons to call are—
 Lost or stolen cards
 Rejected cards
 Questions or information
 Billing disputes
If disputes cannot be satisfied with the supplier, the card provider should be contacted
and the program administrator informed of the dispute. Please remember that the supplier
should be contacted first to resolve billing disputes.

MCPS Program Administrator—301-279-3115 and 301-279-3555

Important reasons to call—
 Card member is changing work locations
 Employment with MCPS is terminated
 Purchasing card use is denied by supplier
 Supplier does not accept American Express
 Other questions

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 PURCHASING CARD AGREEMENT

The Montgomery County Public Schools (MCPS) purchasing card (card) is issued to you subject to the
following terms and conditions. You must comply with these terms and conditions as a requirement for
your employment.

I certify that:

1. I am entrusted with a valuable tool, a purchasing card, and will be making financial commitments on
behalf of Montgomery County Public Schools (MCPS). I understand that MCPS is liable to the card
provider for all charges made on the card.
2. I will strive to obtain the best value for MCPS. I agree to purchase supplies and materials in
accordance with my organizational responsibilities and purchase limits established by the approving
official designated to review my purchases.
3. I will use this card for approved purchases only and must not charge personal items. I am aware of
and understand Board of Education Ethics Policy. MCPS will audit the use of this card and report
and take appropriate action on any discrepancies. I understand that use of the card for personal items
will result in deduction of the total of such unauthorized charges from my payroll check.
4. I will follow the policies and regulations established by MCPS for the use of the card. Failure to do
so may result in either revocation of the card use privileges or other disciplinary action.
5. I acknowledge that all purchases must be made in accordance with applicable laws and regulations,
including but not limited to MCPS Purchasing Card procedures. I understand that persons
intentionally making unauthorized purchases may have their card privileges suspended or be subject
to disciplinary and/or legal action.
6. I have been given a copy of the User Guide for the card. I have read the User Guide and understand
the requirements of the card’s use.
7. If the card is lost or stolen, I will notify the card provider and the MCPS program administrator
immediately. Having done so, if my card or account number is lost or stolen, I will not be personally
responsible for any unauthorized charges.
8. I agree to comply with any changes MCPS may make to the terms and conditions and policies and
procedures concerning the use of the card.
9. I will return the card immediately upon request or upon termination of my employment (including
retirement). Should there be any organizational change that causes my work location (school, office,
department, or division) to change, I will notify the MCPS program administrator and American
Express (see User Guide) immediately.
10. I have attended the MCPS Purchasing Card training and agree to additional training as needed.

As the employee being issued the card, I have read and agree to the terms and conditions stated above. I
certify that, to the best of my knowledge and belief, all of my statements and assertions are true, correct,
complete, and made in good faith and subject to MCPS policies, regulations, and all other applicable
laws. This agreement supersedes any previously signed agreements (as of the date of the signing of this
agreement).

Employee Name (printed): _______________________________________________________

Employee ID #: ________________________________________________________________

School/Location Name: __________________________________________________________

Employee Signature: _________________________________ Date: _____________________

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 Purchasing Card Agreement
Board of Education Member and Executive Staff Member

The Montgomery County Public Schools (MCPS) Purchasing Card (card) is issued to you subject to the terms
and conditions listed below. You must comply with these terms and conditions.

Please certify that:

1. I am entrusted with a valuable tool, a purchasing card, and will be making financial commitments on
behalf of Montgomery County Public Schools (MCPS). I understand that MCPS is liable to the card
provider for all charges made on the card.
2. I will strive to obtain the best value for MCPS. I agree to purchase supplies and materials in
accordance with my organizational responsibilities and purchase limits established by the approving
official designated to review my purchases.
3. I will use this card for approved purchases only and must not charge personal items. I am aware of
and understand Board of Education Ethics Policy. I understand that MCPS will audit the use of this
card and report and take appropriate action on any discrepancies. I understand that use of the card for
personal items will result in deduction of the total of such unauthorized charges from my payroll
check.
4. I will follow the policies and regulations established by MCPS for the use of the card. Failure to do
so may result in revocation of my card use privileges or other disciplinary actions.
5. I acknowledge that all purchases must be made in accordance with applicable laws and regulations,
including but not limited to MCPS Purchasing Card procedures. I understand that persons
intentionally making unauthorized purchases may have their card privileges suspended or be subject
to disciplinary and/or legal action.
6. I have been given a copy of the User Guide for the card. I have read the User Guide and understand
the requirements of the card’s use.
7. If the card is lost or stolen, I will notify the card provider and the MCPS program administrator
immediately. Having done so, if my card or account number is lost or stolen, I will not be personally
responsible for any unauthorized charges.
8. I agree to comply with any changes MCPS may make to the terms and conditions and policies and
procedures concerning the use of the card.
9. I will return the card immediately upon request or upon termination of my term of office or
employment. Should there be any organizational change that causes my work location (school,
office, department, or division) to change, I will notify the MCPS program administrator and card
provider (see User Guide) immediately.
10. I will follow MCPS policy and regulation authorization of travel and dining expenses and promptly
submit required documentation regarding business purpose and participants.
11. I have attended the MCPS Purchasing Card training and agree to additional training as needed.

As the individual being issued the card, I have read and agree to the terms and conditions stated above. I
certify that, to the best of my knowledge and belief, all of my statements and assertions are true, correct,
complete, and made in good faith and subject to MCPS policies, regulations, and all other applicable
laws. This agreement supersedes any previously signed agreements (as of the date of the signing of this
agreement).
Employee Name (printed): ______________________________________________________
Employee ID #: _______________________________________________________________
School/Location Name: ________________________________________________________
Signature: __________________________________________Date:_____________________

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