Get Cell Phone Acknowledgement Form

DIVISION OF ADMINISTRATION Cellular Phone/Mobile Device Policy Acknowledgement and Certification Form I Print Name understand that in accordance with DOA Policy No. 18 regarding cellular phones I will receive an allowance of needed in conjunction with the performance of my job duties. The allowance will be reported as income on my W-2 for tax purposes. This will be the only reimbursement for cellular phone and/or mobile device expenses I receive. I further understand that I may on occasion be required to provide a copy of my cellular/mobile device bill to my supervisor appointing authority or internal auditor for review and to verify that a substantial amount of the usage of the cellular phone/mobile device has been business related therefore a detailed billing receipt may be required* I acknowledge that I have been told that I must maintain cellular/mobile device service in order to receive reimbursement and my failure to do so may subject me to disciplinary action* I also acknowledge that I have read and must comply with the guidelines established in DOA Policy No* 23 Use of Smartphone Devices for Access to State Data* The policy can be located on the DOA/OHR website at http //www. doa*louisiana*gov/ohr/policies/policies2. htm The effective date of this action will be. 1st day of a pay period Employee Signature Personnel No* Date Section Head Signature Appointing Authority Signature Please forward this completed form to the Office of Human Resources. The allowance will be reported as income on my W-2 for tax purposes. This will be the only reimbursement for cellular phone and/or mobile device expenses I receive. I further understand that I may on occasion be required to provide a copy of my cellular/mobile device bill to my supervisor appointing authority or internal auditor for review and to verify that a substantial amount of the usage of the cellular phone/mobile device has been business related therefore a detailed billing receipt may be required* I acknowledge that I have been told that I must maintain cellular/mobile device service in order to receive reimbursement and my failure to do so may subject me to disciplinary action* I also acknowledge that I have read and must comply with the guidelines established in DOA Policy No* 23 Use of Smartphone Devices for Access to State Data* The policy can be located on the DOA/OHR website at http //www. I further understand that I may on occasion be required to provide a copy of my cellular/mobile device bill to my supervisor appointing authority or internal auditor for review and to verify that a substantial amount of the usage of the cellular phone/mobile device has been business related therefore a detailed billing receipt may be required* I acknowledge that I have been told that I must maintain cellular/mobile device service in order to receive reimbursement and my failure to do so may subject me to disciplinary action* I also acknowledge that I have read and must comply with the guidelines established in DOA Policy No* 23 Use of Smartphone Devices for Access to State Data* The policy can be located on the DOA/OHR website at http //www. doa*louisiana*gov/ohr/policies/policies2. htm The effective date of this action will be. 1st day of a pay period Employee Signature Personnel No* Date Section Head Signature Appointing Authority Signature Please forward this completed form to the Office of Human Resources.