"Purchasing Card Cardholder Account Form"

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Purchasing Card Cardholder Account Form
New
Change (Only complete fields to be changed)
Delete/Close
Cardholder Account #
___ ___ ___ ___ - ___ ___ ___ ___ - ___ ___ ___ ___ - ___ ___ ___ ___
Company Information
Company Name:
Cardholder Information
Cardholder Name
Social Security #
(24 Characters)
__ __ __ -__ __ -__ __ __ __
Name Line 2
Date of Birth
(24 Characters)
__ __ / __ __/ __ __
Address Line 1
Mother’s Maiden Name or Password:
(35 Characters)
Address Line 2
Work Phone
:
(35 Characters)
(__ __ __) - __ __ __ - __ __ __ __
City
State
Zip Code
__ __ __ __ __ - __ __ __ __
(23 Characters)
Accounting Code
(optional):
(1- 22 digits)
Reporting Hierarchy Levels (Required Information)
Level 6 Name
(i.e. Approving Official)
Level 6 Number
Reporting Hierarchy Level
Level 2
Level 3
Level 4
Level 5
(i.e.Region)
(i.e.Division)
(i.e.Sub-Unit)
(i.e. Fin. Office)
Numbers
Cardholder Controls (Required unless specified)
Credit Limit (CSL)
Single Purchase Limit
Authorizations Per Day
Transactions Per Cycle
Dollars Per Day (optional)
MCC Group
(Merchant Category Code Group)
Include or Exclude (circle one)
Cardholder Approvals
Prepared By:
Date
(Please Print)
Signature:
Approved By:
Date
(Please Print)
Signature:
(Authorized Signer)
Bank Use Only
Account Number ___ ___ ___ ___ - ___ ___ ___ ___ - ___ ___ ___ ___ - ___ ___ ___ ___
Unit Assigned:
Signature Verified:
Date:
Initials:
Mgt:
chformnew.doc
01/23/98 (Revised 11/22/99)
Purchasing Card Cardholder Account Form
New
Change (Only complete fields to be changed)
Delete/Close
Cardholder Account #
___ ___ ___ ___ - ___ ___ ___ ___ - ___ ___ ___ ___ - ___ ___ ___ ___
Company Information
Company Name:
Cardholder Information
Cardholder Name
Social Security #
(24 Characters)
__ __ __ -__ __ -__ __ __ __
Name Line 2
Date of Birth
(24 Characters)
__ __ / __ __/ __ __
Address Line 1
Mother’s Maiden Name or Password:
(35 Characters)
Address Line 2
Work Phone
:
(35 Characters)
(__ __ __) - __ __ __ - __ __ __ __
City
State
Zip Code
__ __ __ __ __ - __ __ __ __
(23 Characters)
Accounting Code
(optional):
(1- 22 digits)
Reporting Hierarchy Levels (Required Information)
Level 6 Name
(i.e. Approving Official)
Level 6 Number
Reporting Hierarchy Level
Level 2
Level 3
Level 4
Level 5
(i.e.Region)
(i.e.Division)
(i.e.Sub-Unit)
(i.e. Fin. Office)
Numbers
Cardholder Controls (Required unless specified)
Credit Limit (CSL)
Single Purchase Limit
Authorizations Per Day
Transactions Per Cycle
Dollars Per Day (optional)
MCC Group
(Merchant Category Code Group)
Include or Exclude (circle one)
Cardholder Approvals
Prepared By:
Date
(Please Print)
Signature:
Approved By:
Date
(Please Print)
Signature:
(Authorized Signer)
Bank Use Only
Account Number ___ ___ ___ ___ - ___ ___ ___ ___ - ___ ___ ___ ___ - ___ ___ ___ ___
Unit Assigned:
Signature Verified:
Date:
Initials:
Mgt:
chformnew.doc
01/23/98 (Revised 11/22/99)