APPENDIX E, ATTACHMENT II: PURCHASING CARD ACCOUNT MAINTENANCE FORM

Type of Request (Circle One):

A.    New Account    E.    Staff Relocation - New GL:                                           

B.    Address Change    F.    Temporary Increase, Amount:                                       

C.    Account Closure       Reason:                                                                        

D.    Name Change          Date:                                                                     

            G.   Single Transaction Increase:                                        

            H.   Other: Describe                                                    

To Add a New Account (Request "A"):

1. Circle "New Account under Type of Request Above"

2. Complete the section under "Card Information"

To Change Information on an Existing Account (all Other requests):

1.    Indicate Type of Request Above

2.    Fill in Last 8 Digits of Account Number:                                                  

3.    Fill In Current Name on Card:                                                               

4.    Complete only the Fields to be Changed in Card

Information Section:

Name (24 Characters) Embossed on Card   Last 5 Digits of Card Holder's Number

Address (36 Characters Maximum)      Job Title

City (25 Characters Maximum)      Dept/GL Information

State (2 Characters)      Zip Code

Authorization:

Employee Signature          Date

Approving Director Signature      Date

Program Administrator Signature   Date

(Res. 2008-011, passed 2-19-2008)