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Long Distance Code Request & Authorization Form
Complete the form below to request a UTMB long distance code:
Employee Information
Information of the employee that will recieve service
First Name:
*
Last Name:
*
ID Number:
*
Phone Number:
*
Email:
*
Request Information
Select a service:
AT&T Calling Card
Long Distance Code
Teleconference Card
Request Type:
Select one
Add Long Distance Code
Delete Long Distance Code
Change Peoplesoft Chartfield
Change Name
Add AT&T Card
Remove AT&T Card
Other
*
Effective Date:
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November 2009
>
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Phone Number to appear on card:
*
Range Limit:
Select One
Texas Only
Continental U.S. (48 States)
North America (w Canada & Mexico)
International (Overseas)
*
Billing Information
Old Peoplesoft Account Number
(If requesting a change)
Business Unit:
*
Fund Code:
*
Operating Unit:
*
Department ID:
*
Program Code:
*
Class:
*
Project ID:
*
PC Business Unit:
*
Activity:
*
Budget Referance:
*
Peoplesoft Account Number to be charged
Business Unit:
*
Fund Code:
*
Operating Unit:
*
Department ID:
*
Program Code:
*
Class:
*
Project ID:
*
PC Business Unit:
*
Activity:
*
Budget Reference:
*
Signature Authority Information
Contact First Name:
*
Contact Last Name:
*
Contact Email:
*
Contact Mail Route:
*
Contact Phone Number:
*
Additional Information
Comments:
*