HomeMy WebLinkAboutExhibit 4Non-DoD AIR Card Account Enrollment Form
(Please complete the form, Sign it where indicated, and FAX to DESC at (703) 767-8746)
Account Name
DoDAAC/FedAAC/UIC
Branch of Service/Fed Civ Agency
Accountable Official:
Title/Rank
Supplemental DoDAAC
Fund/Signal code
Accounts Payable contact:
Title/Rank
Name
Address 400 NW 2 Ave
City,State/Prov, Postal Code Miami FL 33128
Country
USA
Commercial Phone
DSN Phone
305 579-6413
Fax
E-mail address
305 579--6634
Signature:
(By Signing, the Accountable Official agrees to the Terms and Conditions contained in the Cardholder Agreement)
Name
Billing Address: 400 NW 2 Ave
City,State/Prov, Postal Code Miami , FL 33128
Country USA
Commercial Phone 305 579-5413
DSN Phone
Fax
305 579-6634
Tail Number
A/C Type
Signature:
Card Information.
EC 120
1
N1BnNIP
2
3
4
5
6
7
8
9
DESC Approval:
Date
Signature, Approving Official
Estimated
Monthly Hrs
flown
Estimated Monthly
Gals Used
Comments
50
1550