<p> University of Oxford University Offices, Wellington Square, Oxford OX1 2JD</p><p>Application for an Oxford Bus Company Bus Pass</p><p>Details of person requesting bus pass:</p><p>Full name ...... </p><p>Department ...... </p><p>Payroll number ...... </p><p>Serial number of smartcard to be topped-up ...... </p><p>Please order a 13 week / 52 week (delete as applicable) ______(insert type of bus pass) on my behalf starting on the______(please specify the start date for _ your pass which must be at least 10 working days after the receipt of this application at Facilities Helpdesk).</p><p>I understand that this currently costs £______(insert cost of pass), is repayable in monthly instalments of £______(insert monthly cost) over the term of the pass and I authorise the University to deduct this from my salary.</p><p>I also understand that should I leave the University's employment before the loan is repaid in full, the full outstanding balance becomes repayable immediately and that some or all of this balance will be deducted from my final salary.</p><p>Should you wish to surrender your pass before the expiry date you should note that any refund will be made at the bus company’s discretion.</p><p>Signed ...... </p><p>Date ...... </p><p>Contact Tel No and Email ...... </p><p>Please return this form to Facilities Helpdesk at the above address no later than 10 working days before your specified start date for the pass and indicate below how you would like to receive your pass (We are not liable for any loss or expense incurred due to a lost pass sent via the internal messenger):</p><p>Please automatically top-up my existing smartcard onboard the bus</p><p>I will collect my new smartcard in person from Reception, University Offices, Wellington Square</p><p>Please send my new smartcard via the messenger service to the following university address:</p><p>...... </p><p>...... </p><p>For Payroll Office</p><p>Pay Group …………….. Rec. deduction Type A £ ……………. per month £ ……………. Balance</p><p>Facilities Helpdesk Tel: +44 (0)1865-270087 Fax: +44 (0)1865-270569 E-Mail: [email protected] Web: www.ox.ac.uk</p>