"Travel Card Application/Agreement" - Arkansas

Travel Card Application/Agreement is a legal document that was released by the Arkansas Department of Transformation and Shared Services - a government authority operating within Arkansas.

Form Details:

  • Released on August 1, 2019;
  • The latest edition currently provided by the Arkansas Department of Transformation and Shared Services;
  • Ready to use and print;
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  • Fill out the form in our online filing application.

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TRAVEL CARD APPLICATION
Arkansas Department of Transformation and Shared Services
Office of State Procurement
If you have any Accounts Payable duties or functions, a Travel Card will not be issued.
Section A – Employee Applicant Information
*
Please Print Legibly
Required Fields
Last
Name*
First
Name*
Middle Initial
Social Security Number –
AASIS Personnel
Number*
Last 4
Digits*
Business Mailing
Address*
City*
State*
ZIP
Code*
AR
Area Code - Business
Telephone*
Email
Address*
Emergency Contact Number Include Area
Code*
Special Embossing on Card (if applicable)
Does applicant have Accounts Payable roles? If so applicant cannot be a
Yes
No
cardholder.*
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 Number – Last 4
Managing Account
Name*
digits*
Agency Business
Area*
Default General Ledger
Default Internal Order
WBS Element
Funds Res#
*
Default Cost Center
5020008000
*
Monthly Requested Limit (Limits > $20,000 require additional approval)
Monthly Requested Limit (If monthly purchase limit > $20,000 we recommend
*
single purchase limit of < $20,000)
Section C – Employee Understanding/Signature
*Required Signatures
Employee Applicant requests that he/she be issued a U.S. Bank Visa Travel Card. In consideration of this issuance and the use of the U.S.
Bank T-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 travel pursuant to State Travel Regulations found at
https://www.dfa.arkansas.gov/accounting-office/travel-regulations1/, policies found in the Travel 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 $20,001 and above require approval from Agency Director, Chair if Board/Commission, or Dean if College/University
Print
Name:
Title:
Date:
Signature:
DTSS CREDIT CARD SECTION USE
Card Number
Signature
Date
Revised 08/2019
TRAVEL CARD APPLICATION
Arkansas Department of Transformation and Shared Services
Office of State Procurement
If you have any Accounts Payable duties or functions, a Travel Card will not be issued.
Section A – Employee Applicant Information
*
Please Print Legibly
Required Fields
Last
Name*
First
Name*
Middle Initial
Social Security Number –
AASIS Personnel
Number*
Last 4
Digits*
Business Mailing
Address*
City*
State*
ZIP
Code*
AR
Area Code - Business
Telephone*
Email
Address*
Emergency Contact Number Include Area
Code*
Special Embossing on Card (if applicable)
Does applicant have Accounts Payable roles? If so applicant cannot be a
Yes
No
cardholder.*
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 Number – Last 4
Managing Account
Name*
digits*
Agency Business
Area*
Default General Ledger
Default Internal Order
WBS Element
Funds Res#
*
Default Cost Center
5020008000
*
Monthly Requested Limit (Limits > $20,000 require additional approval)
Monthly Requested Limit (If monthly purchase limit > $20,000 we recommend
*
single purchase limit of < $20,000)
Section C – Employee Understanding/Signature
*Required Signatures
Employee Applicant requests that he/she be issued a U.S. Bank Visa Travel Card. In consideration of this issuance and the use of the U.S.
Bank T-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 travel pursuant to State Travel Regulations found at
https://www.dfa.arkansas.gov/accounting-office/travel-regulations1/, policies found in the Travel 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 $20,001 and above require approval from Agency Director, Chair if Board/Commission, or Dean if College/University
Print
Name:
Title:
Date:
Signature:
DTSS CREDIT CARD SECTION USE
Card Number
Signature
Date
Revised 08/2019
State of Arkansas
Travel Card/ CTS Agreement Form
Check all that apply:
Travel card
CTS account
Printed Name:
Agency/ Business Area:
As an authorized and approved Arkansas Travel Card and/or Account Number holder, I fully understand and 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 Travel/CTS 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 Travel 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 charge family members travel expenses on my card and/or account, will not make personal food
purchases on my card and/or account without prior approval from the Office of Accounting.
6.
Will not use the Travel Card and/or Account Number for non-state official business, unauthorized, or personal
purchases. If such charges occur I will be required to reimburse the State and 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.
7.
Will immediately report the theft or loss of the Travel Card and/or Account Number to, US Bank by phone at 1-
800-344-5696 and my Agency P Card Liaison. Failure to notify the appropriate authority of the immediate theft, loss, or
the misplacement of the travel Card and/or Account Number will make me personally responsible for any fraudulent or
unauthorized use.
8.
Will surrender the Travel Card and/or Account Numbers 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 State
Credit Card Manager requests surrender of my card.
9.
Understand that I am responsible for obtaining all original detail receipts and submit them in accordance with
my agencies policy and the Arkansas Travel 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 Travel
Card and/or Account Number(s) in any manner may result in (a) revocations of the privilege to use the card/account, (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 cardholder and/or account custodian.
Employee signature
Date Signed
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