FIU One Card
Affiliate Card Application Form
“Please fill out and submit the following form to the FIU One Card office in PG 1 – 100.
If you have any questions, please call: (305) 348-2273 or email: [email protected].”
FOR DEPARTMENTS ONLY:
“Please fill out and submit the following form.
If you have any questions, please call: (305) 348-2273 or email: [email protected].”
Please Check One:
Affiliated Department Pays
(must also present fully executed Inter-Departmental Transfer Form)
Cardholder Pays
Cardholder
First Name:
Middle Name:
Last Name:
Panther ID#:
Title:
University Department:
Dept. ID#
Affiliation:
Visiting Faculty
Visiting Research Staff
Courtesy Employee
Other
If Other, please detail:
Authorized University Department Contact:
Phone Number:
Email Address:
Name of Person Completing Form (if different):
x
I represent that I am the authorized signer for the terms listed above.
Date:
IMPORTANT NOTICE: An FIU One Card will only be issued upon presentation of this form and a government- issued photo I.D. (i.e., driver's license,
passport, etc.). If Cardholder is paying for the cost of the card, a payment of $10.00 must be made in cash at the FIU One Card Office located at:
(MMC) Ground Floor, Gold Garage/PG-1 or (BBC) WUC 143, Wolfe University Center. Departments may use ID Transfers as a form of payment.tt