Employee Petrol Card Reissue

EMPLOYEE PETROL CARD REISSUE

This form documents an employee request for reissue of a company petrol/fuel card. Completion of this form constitutes an acknowledgement of the company's fuel card policy, authorization for the company to deactivate any previously issued card, and acceptance of the terms set forth below. Employee must provide accurate information and supply supporting documentation where required.

Personal Information

Position Information

Petrol Card Details / Reissue Request

Current/Previous Card Number (if known):

Request Type (select applicable): Lost Stolen Damaged Expired Name Change Other

Date of incident or reason effective date:

If stolen, Police Report Number (if filed):    Police Station / Jurisdiction:

Will you return the old card if found? Yes No

Declaration, Liability and Authorization

By signing below I certify under penalty of disciplinary action that the information provided is true and complete. I acknowledge the petrol card is issued for official business only. I will comply with all company fuel card policies, will report loss or theft immediately, and will surrender any previously issued card upon request. I understand that I remain responsible for any charges resulting from negligent or fraudulent use of a card issued in my name until such card is reported and deactivated, and the company may recover such charges through payroll deduction or other lawful means.

I authorize the company to deactivate any previously issued card associated with my name and to issue a replacement card. I acknowledge that a replacement fee may apply and that the company may set activation limits and usage controls on the replacement card. I agree to immediately return this card upon termination of employment or upon request by the company.

Employee acknowledges and agrees that misuse, intentional violation of card policy, or failure to report a missing card may result in disciplinary action up to and including termination, and may give rise to civil or criminal liability.

Employee Agreement: I have read and accept the terms above

Replacement Fee and Payment

Replacement Fee Amount (if applicable):    Payment Method:

Human Resources / Fleet Administrator Use Only

Action Taken: Deactivated old card Issued replacement Hold pending investigation

New Card Number Assigned:    Activation Date:

Employment History

Education

References

Legal Disclosures

At-Will Employment Statement: Nothing in this request or in the issuance of a petrol card constitutes a contract of employment. Employment remains at-will and may be terminated by either the employee or the employer at any time, with or without cause, subject to applicable law.

Equal Opportunity Statement: The company provides equal employment opportunity and does not discriminate in any personnel action. Completion of this form will not be used as the basis for discriminatory practices.

Applicant Certification & Authorizations

I certify that all information provided on this form is true and complete. I understand that false statements may result in disciplinary action. I authorize the company to contact prior employers for the purpose of verification and I consent to any reasonable background checks required for issuance of a company petrol card.

I authorize contact with prior employers I consent to background checks

I understand that issuance of a replacement card is at the discretion of the company and may be subject to conditions, including but not limited to investigation of loss/theft and payment of replacement fees.

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