Credit Card Holder Acknowledgment Form
I, , an employee or officer of the City of Centerville, acknowledge: that I:
1. have received a copy of the City's Credit Card Policy and Procedures, and
2. have read and understand the City's Credit Card Policy and Procedures, and
3. agree to conform to all the conditions and requirements of the City's Credit Card Policy and Procedures, and
4. accept personal responsibility for the safeguard and proper use of any and all City credit cards, which either have been provided to me or "checked out" for use in performance of my City duties, and
5. understand that I am personally liable for the misuse of any City credit cards provided to me or "checked out" by me, and
6. shall be held personally responsible for the misuse of any City credit cards provided to me or "checked out" by me, and
7. shall be held personally responsible for inappropriate charges made on any City credit cards provided to me or "checked out" by me, and
8. shall be held personally responsible for failing to timely provide the Director of Finance with itemized receipts, and
9. shall be held personally responsible for failing to timely notify the Director of Finance that a City credit card(s) provided to me or "checked out" by me is lost or compromised, and
10. understand the Director of Finance or the City Manager, shall, at a minimum, discontinue my use of a City credit card for violation or misuse of the credit card, and
11. understand my misuse of any City credit cards may lead to discipline, which could include termination/demotion, and
12. understand my misuse of any City credit cards may subject me to potential criminal penalties in addition to potential discipline, and
13. hereby authorize that any inappropriate charges may be withheld from my salary.
Employee's Printed Name Employee's Signature
Date