New Card     	New Card Number _________________________________
       Replacement  	Old Card Number _________________________________
       Cancel Card  	Old Card Number _________________________________

Cardholder Name_______________________  Phone  ___________  Title __________________________          

HIGH FRAUD COUNTRY LIST
Access to the following countries is automatically blocked on all calling cards.
If you want access to any of these countries, place an X beside the country name.
Please remember that you will be responsible for ALL calls. 

  Bangladesh    Brazil                 China            Columbia 
  Equador       Dominican Republic     Egypt            El Salvador 
  Guatemala     Honduras               India            Mexico 
  Pakistan      Peru                   Philippines      Senegal  

BILLING INFORMATION: 

Department _____________________________  Org Code _______________ Index _______________ 

REQUEST APPROVAL: 

Dean, Director, Department Head or Manager's Signature: 

____________________________________________           ___________________________________________
Signature                                              Print Name 

CARD RECEIPT:By accepting this calling card and signing receipt you acknowledge your
responsibilities under "Long Distance Telephone Calls" Policy 2110,UBP.Report lost
or stolen cards to the University Telecommunications Department immediately.  
Cardholder must sign receipt. 

Cardholder Signature: _______________________________   Date: _______________________________