USNH Purchasing Card Application

Last updated: 26-Jul-2004
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USNH Purchasing Card Application

* indicates required fields

* Request Type (Defined)

Individual Account
Departmental Account
Sponsor Account
Convenience Checkbook Account - Number of books

**Cardholder Information**
*First Name:	*Last Name:	*Social Security Number:

*Date of Birth:	*Mother's Maiden Name:	*Campus Phone:

Cardholder Campus Address: (For use as verification/billing address) Provide the Department Name, Building, Room, Street Address, City, State, Zip
*Address:		*Campus:

**Card Information**
*MCC Code: (Defined)	If USNHAIR is chosen, will the cardholder be responsible for purchasing travel for others?
	Yes No
Card Description (Defined):	* Daily PCard transaction notifications and monthly statements should be emailed to:

*Max Dollars per Transaction:	*Max Number of Transactions per Day:

*Max Dollars per Month:	*Max Number of Transactions per Month:

If the above limits do not meet your needs, leave blank and email the Campus Card Administrator.

**Departmental Information**
Account Manager	*First Name:	*Last Name:	*Banner Username:
Account Manager
Business Manager	*First Name:	*Last Name:	*Banner Username:
Business Manager

Default Account Information	*Fund:	*Org:	*Account:	Activity (optional):	*Responsible Org
Default Account Information

**Sponsor Information**
A Sponsor is required if the cardholder has a non-status appointment. Sponsor must be a benefits-eligible employee. Sponsor must sign the Sponsor Authorization section of the application. *All fields are required if a Sponsor is applicable.
First Name:	Last Name:	Social Security Number:

Date of Birth:	Mother's Maiden Name:	Campus Phone:

Signature Page: Type the name and date for each section below and then follow the instructions at the end or verify accuracy of the form now, and then print and complete the signature page manually.

Cardholder Authorization

I request a purchasing card be issued to me. I agree to comply with all institutional policies and procedures regarding proper use and safekeeping of the card and understand that goods are to be purchased solely for institutional purposes. I agree that failure to comply with these conditions may result in the withdrawal of the privilege of using the purchasing card. I further understand that purposeful, fraudulent or negligent behavior on my part regarding use of the card will be considered serious misconduct and may result in disciplinary action up to and including termination or legal action, as stipulated in the USNH Cardholder's Guide.


Signature	Name	Date

Sponsor Authorization (Required if cardholder has a non-status appointment)

I hereby authorize a purchasing card be issued to the individual whose name appears above. Additionally, I authorize this person to make institutional purchases on my behalf, and I will review those purchases monthly. I agree to notify immediately my business manager when the above referenced individual either terminates or separates from this department or whenever a purchase made by this person appears not to meet USNH policies.


Signature	Name	Date

Departmental Authorization

I hereby authorize a purchasing card be issued to the individual named above. I understand that the department will be held responsible for the proper use of the card including ensuring that all charges are posted to the appropriate accounts and maintaining the required records for all card transactions.


Signature	Name	Date

DO NOT COMPLETE THIS SECTION UNTIL CARD HAS BEEN RECEIVED AND TRAINING HAS TAKEN PLACE

Cardholder Acceptance

I certify that I have read and understand the policies and procedures on the appropriate use and handling of the purchasing card and do hereby agree to comply with them. I also agree to surrender this card to my departmental account manager or business manager upon request or upon my termination/separation from this department.


Signature	Name	Date

Witnessed by Campus Card Administrator:

Signature	Name	Date