Purchasing Card Application for the SELECT PROGRAM

Please type or print clearly and completely. Incomplete applications will be returned. Cardholder’s Name* (First Name – Middle Initial - Last Name) Cardholder DOB (MM/DD) Last 4 Digits of Social Security Number

Please Print: requiring only the 2 digit month & 2 digit day

__ __ / __ __ Cardholder’s Position / Title Cardholder’s Business E-mail address

Cardholder’s Department Phone Extension

Cardholder’s Default Coding (Banner Budget Number)

Fund Organization Program

Application Form Must be Signed by both the Applicant and Financial Manager* If Applicant/Cardholder is the Financial Manager, have supervisor sign Completed form should be sent by campus mail or faxed (3499) to Procurement Services. The cardholder will be notified when the card arrives (approximately 2 weeks).

Cardholders are initially assigned spending limits of $1,500 per transaction and $15,000 per month credit limit. A request for higher limits than these may be made by the Financial Manager by attaching a memo documenting the necessity for the higher limits.

Please state the reason(s) why a Select card is needed:

Cardholder’s Signature (Required On All Applications) Date

Financial Manager’s Name* (please print) Financial Manager’s Phone Financial Manager’s Business E-mail Address Extension

Financial Manager’s Signature (Required On All Applications) Date *If Applicant/Cardholder is the Financial Manager, have supervisor sign.

For Administrative Use Only: Cardholder Spending Limits Single transaction limit $______ULSA TECHNOLOGY CENTER Monthly limit $ ______

2nd Line Embossing: PaymentNet User ID: ______□ Recommend □ CM ______Accts Manage □ Do not Recommend ______□ MCC group ______Director, Procurement Services Date □ Employee Manage Pass Phrase ______□ Approve □ CH Setup (SOA/Query/email) □ Deny ______□ Last 4 digits of card ______Controller Date □ CH Agreement □ Email □ Training ______□ CHL ______(day) (date) (time) □ Pcard User Group □ Login Form YoungstownStateUniversity_SelectCardholderApplication 01/17/13