Please use this form to reimburse charges for non-business use of a Curtin mobile phone. Cash or cheque payments are to be made in person at Curtin Cashier (Building 101)

A.Total Ex Gst charges for non-business use of this service including SMS 	$28.12	
B. Ex Gst Promotion Discount	$-1.63	
C. Total charges for non-business international calls and SMS (GST Exclusive charges). 	$2.20	
CASHIERS PLEASE NOTE

Reimbursement is to be distributed to the following cost centres:

	GST Inclusive
Amount	GST
Code	
COST CENTRE/LINE ITEM	$	c		NARRATION	
E - 101201 - 0010 - 70828 
 	26.72		C  Gst Inclusive	DAVID ANTOINE 0401-103402  May 2014	
E - 101201 - 0010 - 70828  
	2.20		F GST Free	DAVID ANTOINE 0401-103402  May 2014	
TOTAL	28.92				

If you wish to pay this amount by Credit Card, please complete the details below and either attend the Cashier in building 101 or fax this form to 9266 4531.

Please debit my account for the following amount: 

E - 101201 - 0010 - 70828  		$ 28.92

Payment is being made for:  DAVID ANTOINE 0401-103402 May 2014

Card Type (circle as appropriate): 	VISA 	MasterCard 	American Express

Cardholder’s Name: ___________________________________________

Card Number:  _______________________________________________	Card Expiry Date: _____ / _____

4-Digit Security Code: (Required for American Express Cards only-
Located above the card number)

Cardholder’s Signature: _____________________________________			Date: ______ / ______

Receipt required YES   /   NO		FORWARD TO  ____________________DEPT / EXTN    ________________________

Payer/receipt to be made out to DAVID ANTOINE
Address________________________________________________________________________________________