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PROCUREMENT
CARD |
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Cardholder Name:
_____________________________________ Department: __________________
Social Security Number:
________________________________ Phone: _______________________
(Last 4 digits)
Email Address: ________________________________________
Cancel Card: Transfer [ ] Termination [ ] Card Misuse [ ] Card Non-Use [ ]
Date Card Returned: _______________________
Change Procurement Card Default Account Number:
From: __________________________ To: __________________________
Add or Delete Procurement Card Account Number (circle your choice):
Add / Delete _____________________________________________________
Add / Delete _____________________________________________________
Add / Delete _____________________________________________________
Change Monthly Spending Limit:
From:
__________________________ To:
__________________________
Cardholder: ______________________________ /
__________________________/__________
Signature
Print Name
Dean/Department Head: _________________________ /
_____________________/___________
Signature
Print Name
Supervisor:/Control Agent:
_______________________ /
_________________________/____________
Signature
Print Name
Pre-Audit (Business Office): ______________________ / ______________________/__________
Signature
Print Name
Date
Program Administrator: __________________________ /
______________________/_________
Signature
Print Name
Date
Business
Office Contracts and
Grants Office Approval (if applicable):____________________/____________________/_________
Signature
Print Name
Date
__________________________________________________________________________________________
Central New Mexico Community College
Updated 6/06