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8150F - Wireless Mobile Device Approval Form

Form 8150F


Wireless Mobile Device Approval Form 

Location/Department:                                            Wireless Mobile Device Number:                                                   

Employee Name:                                                                                                                              

Employee Title:                                                                                                                                

I agree to abide by all the conditions set forth in the Pasco School District policy and procedure 8150. I understand district administered wireless mobile devices are intended and will be used primarily for district business. If I use a district administered wireless mobile device to make or receive personal calls, I understand I am required to promptly reimburse the district for the cost of the call.

Abuse of District Equipment

Devices will not be eligible for replacement or upgrade prior to one year of use. Damages beyond accidental or normal wear and tear will be at the user’s expense or replacement as determined by the supervisor.

In the Event You Leave District Employment

This equipment must be returned, if leaving employment of the district, prior to departure. Failure to do so will subject the undersigned to possible civil and/or criminal prosecution. In addition, I authorize the Payroll Department to deduct the amount of my wireless mobile device charges (non-business) and the device cost, if not paid directly to Fiscal Services, from my final payroll warrant. I understand I may be subject to disciplinary action, up to and including termination of employment for misuse, abuse, loss, or damage of district equipment or otherwise failing to follow policy and procedure 8150.

I have read and agree to abide by policy and procedure 8150. 


Employee Signature                                                                          Date                                      



Superintendent/Designee:                                                                 Date                                         


Wireless Mobile Device Allowance

Authorization Form  

Employee Name:                                                                                                              


Employee Title:                                                                                                                


Location/Department:                                             Wireless Mobile Device Number:                                                  

· The monthly wireless mobile device allowance will be paid each month to the eligible employee.

· This is a non-accountable plan therefore additional receipts and documentation are not required.

· Wireless mobile device allowance is not eligible for reporting to the Department of Retirement Systems.

· Wireless mobile device allowance is subject to applicable payroll taxes.

· The district is not responsible for making changes to the district electronic communication system to accommodate a cell phone device that is not compatible.

· It is the employee’s responsibility to check with the district technology department to make sure a device is compatible with the district electronic communication system prior to the purchase of such a device.


Monthly allowance amount authorized (check one):             $25 Wireless Phone Service Only

            $40 Wireless Phone and Data Services

            $25 Wireless Data Service Only


By accepting the monthly wireless mobile device allowance I do hereby agree to use my own personal wireless mobile device so that I may be reached during regular business hours and non-business hours. I agree to have a working wireless mobile device and to furnish the district with a valid working wireless mobile device number at all times. I further agree to contact my supervisor if I change or cancel wireless mobile device services. Failure to contact my supervisor may result in a repayment of the allowance.


Employee Signature:                                                                            Date:                                        


Supervisor Signature:                                                                          Date:                                        


Supervisor Title:                                                                                 


Eligibility for the allowance is dependent on employee meeting criteria establish in Policy 8150.





PAYROLL: Allowance Set-up

(Initial)                        (Date)