Appendix 1
UW-EXTENSION
CARDHOLDER ACCOUNT SETUP FORM
New
Delete
Change (only complete fields will be changed)
Cardholder Account #: __ __ __ __ - __ __ __ __ - __ __ __ __ - __ __ __ __ (16 digit #)
(Must complete for change or delete)
CLIENT INFORMATION
Client Name: University of Wisconsin - Extension
CARDHOLDER INFORMATION
Cardholder Name: (24 characters)
__ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __
Social Security #:
999 - 99 - 9999
Name Line 2: (Third Embossed Line=24 characters. If this field is not completed, we will print Client Name on the Card.)
Tax Exempt ES40706
(US Bank Use: Use Authorized User 1 Field)
Address Line 1: (35 characters)
__ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __
Address Line 2: (35 characters) (Note: The Card will be mailed directly to this address)
__ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __
City: (23 characters)
__ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __
State:
Zip Code:
Business Telephone:
(
)
Accounting Code (Optional-22 Character Maximum):
REPORTING HIERARCHY INFORMATION
Company Level #1
70073
Level 2 #
Level 3 #
Level 4 #
Level 5 #
Level 6 #
Level 7 #
For verification, enter the Name of Unit that this cardholder points to: ________________________________
CARDHOLDER LIMITS
Monthly Credit Limit($): __________________________
Single Purchase Limit($): ________________________
$ Limit Per Day: ________________________________
Transactions Per Cycle (#): ______________________
MCC Group: 1001
I (Include) or E (Exclude): Circle One
ACCOUNT ACCESS METHODS
Should a card be issued?
Yes
No (US Bank Use: If "No", Order List of Account #'s)
Should a pin be issued?
Yes
No
Should checks be issued?
Yes
No
CARDHOLDER APPROVALS
Departmental Chairperson: ______________________________________________ Date: ______________________
Dean/Director Signature: _______________________________________________ Date: ______________________
Authorized Agency Signature: ____________________________________________ Date: ______________________
Telephone Number: ________________
Fax Number: _____________________
(see instructions on back of form)
CARDHOLDER ACCOUNT SETUP FORM INSTRUCTIONS
NEW – Check the “New” option when requesting a new card be issued.
Cardholder Account # - Leave blank when requesting a new card
Client Name – Pre-entered
Cardholder Name – Enter the name of the cardholder
Social Security # – Pre-entered with 9’s—individual SS# is not be entered.
Name Line 2 – Pre-entered
Address Line 1, Address Line 2, City, State, Zip Code and Business Telephone– Enter the
cardholder’s address. Use line 1 for building and/or room number. Use line 2 for the street. Enter city,
state and zip code. Note: This is the address that US Bank will use for mailing the cardholder’s purchasing
card. Enter the cardholder’s business telephone number, include area code.
Accounting Code – Enter primary Fund-Department-Program-Project/Grant (if appropriate) coding to
which purchases should be charged. Do not show spaces or enter dashes. For example, Fund 144,
Project/Grant 144AB21, Department 419900, Program 5 would be entered 1444199005144AB21; and if it is
Fund 104, it would be entered as 1044199005.
Reporting Hierarchy Information – Leave Blank – Will be completed by Agency Representative.
Cardholder Limits – Leave Blank – Will be completed by Agency Representative.
Account Access Methods – Leave Blank – Will be completed by Agency Representative.
Cardholder Approvals – The department chair or designee and dean/director or designee must sign
and date.
DELETE – Check the “Delete” option if a cardholder is to be terminated (i.e., the cardholder is no longer
employed at UW-Extension).
Cardholder Account # – Enter cardholder’s number.
Cardholder Information – Enter cardholder’s name.
** CUT THE PURCHASING CARD IN HALF AND FORWARD ALONG WITH APPENDIX 1
THROUGH THE DEPARTMENT CHAIR AND DIVISIONAL BUSINESS OFFICE TO THE
THE UW-EXTENSION BUSINESS SERVICES OFFICE.**
CHANGE – Check the “change” option and complete the following:
Cardholder Account # - Enter cardholder’s number.
Fill in field that needs to be changed – Enter either changed address or accounting code.