University of Arizona Purchasing Card Account Form

The University of Arizona
Departmental Purchasing Card Visa Application
 

Appendix C - 05/03

Instructions:
  1. Complete the form. TAB to access each field.
  2. Press the "Submit" button located at the bottom.
  3. Print the application that is provided.
  4. Obtain required signatures (Responsible Employee, Liaison, Department Head)
  5. Send to Misty McCormick, Purchasing Card Coordinator, Procurement & Contracting Services, USA Bldg 300A.
New Application (Obtain Responsible Cardholder Signature)

Allow Airline / Transportation for employee travel?  Yes      No
Cardholder Information
Responsible Employee  Name
(24 Characters)		 College Name
(30 Characters)
Department Name
(24 Characters)		 Department Number
(4 or 5 Characters)

The Campus Address will determine where the cardholder's statements are mailed. If they are to go to a central location in your unit, use that location for the Campus Address for every cardholder. Be sure to inform each cardholder what Campus Address has been used on their application form. It is that address that they should give to merchants if asked for their billing address. Giving any other address will result in a declined transaction.
 

Campus PO BOX 
(7 Characters)		 Work Phone: ()-
Campus Street Address
(25 Characters)		 City
(23 Characters)
State Zip Code -

Fill in the FRS 6 digit account and 4 digit object code to be used as the default for the card.
FRS Account
(6 characters)		 FRS Object Code
The following pieces of information will be sent in an encrypted email message. They will not appear on the form that will be mailed to the System Coordinator. The System Coordinator will decrypt them, enter them on the form for use by JPMorgan Chase in issuing the Purchasing Card, and save the message as encrypted. This is done for the protection of our employees credit status and records.

EID # -- Activation Password 
(10 characters)

Cardholder Controls
Single Purchase Limit:
(Must be $5,000 or less)		 $ Purchases per month
Credit limit:		 $
Number of Transactions per Day: Number of Transactions per Month:

Reconciler and Approver Information

The reconciler and approver EID's and email's will be sent in an encrypted email message. They will not appear on the form that will be mailed to the System Coordinator.

Reconciler:
Name EID  - - UA NET ID
E-mail: 
Send Email Notification for Pending Transactions to reconciler?  Yes   No
Approver:
Name EID - - UA NET ID
E-mail: 
Send Email Notification for Pending Transactions to approver?  Yes   No