"Purchasing Card Application Form" - Arkansas

Purchasing Card Application Form is a legal document that was released by the Arkansas Department of Finance & Administration - a government authority operating within Arkansas.

Form Details:

  • Released on March 1, 2014;
  • The latest edition currently provided by the Arkansas Department of Finance & Administration;
  • Ready to use and print;
  • Easy to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of the form by clicking the link below or browse more documents and templates provided by the Arkansas Department of Finance & Administration.

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Download "Purchasing Card Application Form" - Arkansas

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PURCHASING CARD APPLICATION
Arkansas Department of Finance & Administration – Office of State Procurement
If you have any Accounts Payable duties or functions, a Purchasing Card will not be issued.
Section A – Employee Applicant Information
*Required Fields
Please Print Legibly
Last
Name*
First
Name*
Middle Initial
Last 4 Digits of SS
Number*
AASIS Personnel
Number*
Business Mailing
Address*
City*
State
ZIP
Code*
AR
Area Code - Business
Telephone*
Email
Address*
Special Embossing on Card (if applicable)
Section B - Agency Accounting Information
*Required Fields
This section is to be completed by an authorized Agency Program Liaison.
Agent –4 digits
Company – 5 digits
Division (if applicable) – 5 digits
Department (if applicable) 4 digits
*
*
Managing Account Name
Managing Account Number 16 digits
Agency Business
Area*
Default General Ledger
Default Internal Order
WBS Element
Funds Res#
*
Default Cost Center
5020007000
0995
*Monthly Requested Limit (limits >$10000, requires additional approval)
*Single Purchase Limit (limits >$5000 requires additional approval)
Section C – Employee Understanding/Signature
*Required Signatures
Employee Applicant requests that he/she be issued a U.S. Bank Visa Purchase Card. In consideration of this issuance and the use of the U.S.
Bank P-Card, the Employee Applicant and State agree to be bound by the U.S. Bank Cardholder Agreement accompanying the card, as
amended by U.S. Bank from time to time, for all charges incurred by the use of the card or the related account. Creditor is U.S. Bank National
Association ND.
I, the undersigned cardholder, understand that this card is to be used for official state purchases pursuant to State Purchasing Regulations
found at
http://www.dfa.arkansas.gov/offices/procurement/Documents/lawsRegs.pdf
, policies found in the Purchasing Card Policy and
Procedure Manual, and agency purchasing regulations. The State is liable and responsible for payment of the bill in full. As a cardholder, I
agree to make no personal charges on the card. I further understand that if I abuse this privilege, my card may be cancelled by my issuing
state entity or the Office of State Procurement.
*Employee
*Date:
Signature:
*Liaison
*Liaison
*Date:
Name:
Signature:
*Approving
*Approving
Manager
Manager
*Date:
Name:
Signature:
Section D –Exception -Credit Limit Required Signatures
Credit Limits $10,001-$24,999, Requires Approval from the Agency CFO or Dept. Chair of College/ University
Print
Name:
Title:
Date:
Signature:
Credit Limits $25,000 and above, Requires Approval from the Agency Director or Chair of Board/Commission or Dean of College/ University
Print
Name:
Title:
Date:
Signature:
DFA CREDIT CARD SECTION USE ONLY:
Card Number
Signature
Date
REVISED 03/2014
PURCHASING CARD APPLICATION
Arkansas Department of Finance & Administration – Office of State Procurement
If you have any Accounts Payable duties or functions, a Purchasing Card will not be issued.
Section A – Employee Applicant Information
*Required Fields
Please Print Legibly
Last
Name*
First
Name*
Middle Initial
Last 4 Digits of SS
Number*
AASIS Personnel
Number*
Business Mailing
Address*
City*
State
ZIP
Code*
AR
Area Code - Business
Telephone*
Email
Address*
Special Embossing on Card (if applicable)
Section B - Agency Accounting Information
*Required Fields
This section is to be completed by an authorized Agency Program Liaison.
Agent –4 digits
Company – 5 digits
Division (if applicable) – 5 digits
Department (if applicable) 4 digits
*
*
Managing Account Name
Managing Account Number 16 digits
Agency Business
Area*
Default General Ledger
Default Internal Order
WBS Element
Funds Res#
*
Default Cost Center
5020007000
0995
*Monthly Requested Limit (limits >$10000, requires additional approval)
*Single Purchase Limit (limits >$5000 requires additional approval)
Section C – Employee Understanding/Signature
*Required Signatures
Employee Applicant requests that he/she be issued a U.S. Bank Visa Purchase Card. In consideration of this issuance and the use of the U.S.
Bank P-Card, the Employee Applicant and State agree to be bound by the U.S. Bank Cardholder Agreement accompanying the card, as
amended by U.S. Bank from time to time, for all charges incurred by the use of the card or the related account. Creditor is U.S. Bank National
Association ND.
I, the undersigned cardholder, understand that this card is to be used for official state purchases pursuant to State Purchasing Regulations
found at
http://www.dfa.arkansas.gov/offices/procurement/Documents/lawsRegs.pdf
, policies found in the Purchasing Card Policy and
Procedure Manual, and agency purchasing regulations. The State is liable and responsible for payment of the bill in full. As a cardholder, I
agree to make no personal charges on the card. I further understand that if I abuse this privilege, my card may be cancelled by my issuing
state entity or the Office of State Procurement.
*Employee
*Date:
Signature:
*Liaison
*Liaison
*Date:
Name:
Signature:
*Approving
*Approving
Manager
Manager
*Date:
Name:
Signature:
Section D –Exception -Credit Limit Required Signatures
Credit Limits $10,001-$24,999, Requires Approval from the Agency CFO or Dept. Chair of College/ University
Print
Name:
Title:
Date:
Signature:
Credit Limits $25,000 and above, Requires Approval from the Agency Director or Chair of Board/Commission or Dean of College/ University
Print
Name:
Title:
Date:
Signature:
DFA CREDIT CARD SECTION USE ONLY:
Card Number
Signature
Date
REVISED 03/2014
State of Arkansas
Purchasing Card Agreement Form
0995 Arkansas Department Of Emergency Management
Printed Name:______________________ Agency/ Business Area:______________________________
As an authorized and approved Arkansas Purchasing Cardholder, I fully understand agree to the
following terms and conditions regarding the use and safekeeping of the credit card(s) and/or account
number (s) entrusted to me:
1. I have or will receive training on the Purchasing Card policy and procedures.
2. I acknowledge that I do not have any accounts payable duties or functions; and that if I do my card
privileges may be revoked.
3. Accept full personal responsibility for the safekeeping of the Purchasing Card and/or account number
assigned to me and that absolutely no one, other than me, has authority to use the card and/or account
number assigned to me or make charges on the card and/or account.
4. Will be making financial commitments on behalf of the State of Arkansas and will always endeavor to
obtain fair and reasonable prices.
5. Will not use the Purchasing Card and/or account numbers for non-state official business,
unauthorized, or personal purchases. If such charges occur I may be required to reimburse the State not
the bank for all incurred charges and any fees related to the collection of those charges and do all such
other things to remedy the situation.
6. Will immediately report the theft or loss of the Purchasing Card and/or account number to, US Bank
by phone at 1-800-344-5696 and my Agency Purchasing Card Liaison. Failure to notify the appropriate
authority of the immediate theft, loss, or the misplacement of the Purchasing Card and/or Account
Number will make me personally responsible for any fraudulent or unauthorized use.
7. Will surrender my Purchase Card and/or account number upon (a) my termination of employment
with the State of Arkansas, or (b) retirement, or (c) transfer to another agency within the state, or (d) my
supervisor or the OSP Credit Card Manager requests surrender of my card(s).
8. Understand that I am responsible for obtaining all original detail receipts and submit them in
accordance with my agencies policies and the Arkansas Purchasing Card Program’s policies and
procedures.
I understand that failure to follow any of the above listed terms and conditions or if found to have
misused the Purchasing Card in any manner may result in (a) revocations of the privilege to use the card,
(b) disciplinary action, (c) termination of employment, and/or criminal charges being filed with the
appropriate authority. I hereby accept the above terms and conditions.
This agreement includes all future types of accounts as a cardholder and/or account custodian.
_____________________________________
_____________________________
Employee Signature
Date Signed
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