TELECOMMUTING FACILITY REIMBURSEMENT INFORMATION SHEET
  • REQUEST DATE

    • 2. CONTROL NUMBER(GSA Use only)

  • AGENCY NAME

  • TELECENTER WORK SITE

    • 5A. AGENCY CONTACT

    5B. CONTACT

    TELEPHONE NO.

    AREA CODE

    PHONE NUMBER

    EXT.

    5E. CONTACT ADDRESS

     

     

    5C. CONTACT

    FAX NUMBER

    AREA CODE

    PHONE NUMBER

    5D. E-MAIL

    6. FLEXIBLE WORKPLACE PROGRAM SUMMARY : List employee's name , days of telecenter usage and monthly costs below. Fees and usage below (ex: 3 days @ $54 = total monthly cost of $162.00) (30-days notice is required for fee adjustments related to unused workstation days):.

    WEEKLY USAGE

    EMPLOYEE NAME                                               MON        TUE        WED        THU        FRI          MONTHLY COST ($'S)

     

     

     

     

     

     

     

     

     

     

    TOTAL COSTS:

     

    1) This payment document will be submitted to GSA on an annual basis. 2) The user will give the center director 30-days notice prior to vacating a telecenter or requesting fee adjustments and notify the appropriate user agency personnel. 3) The telecenter director will notify GSA of the use termination by signing in Section 18 and forwarding a copy of this document to GSA, PBS, Business Performance.

    CHECK AS APPROPRIATE:

    10. REQUESTED SERVICE DATES:

    13A. FED CODE

    13B. BUREAU CODE

    7. New User

    A. START:

    8. Amendment

    B. COMPLETION:

    14A. AGENCY FINANCE BILLING ADDRESS

    9A. BILLING TYPE

    9B. BILLING TERMS

    11. AGENCY CERT. AMT.

    14B. STREET ADDRESS

    12A. AGENCY LOCATION CODE

    12B. AGENCY ID #

    12C. FUND CODE

    14B. CITY

    14C. STATE

    14D. ZIP CODE

    12D. AGENCY ACCOUNTING DATA: (LIMITED TO 60 CHARACTERS)

    16A. CREDIT CARD NUMBER

    16B. EXP. DATE

    16C. TYPE OF CARD

    (i.e., VISA)

    16D. CARD HOLDER NAME

    (TYPE OR PRINT)

    15A. CERTIFYING OFFICIAL'S SIGNATURE

    15B. DATE

    17. CERTIFYING OFFICIAL'S PHONE NUMBER

    15C. NAME OF SIGNER (Type or Print)

    AREA CODE

    PHONE NUMBER

    EXT.

    GSA & Center Director Records:

    POINT OF SALE TERMINAL (For Credit Card Purchases Only)
    ___ A. FINANCE ____ B. PBS

    18. CENTER DIRECTOR TERMINATION SIGNATURE

     

    SIGNER'S NAME (Type or Print)

    25C. DATE

    (This sheet may be photocopied)