BONNEVILLE COUNTY REQUEST FOR CREDIT CARD
CARD ACCEPTANCE/ACKNOWLEDGEMENT FORM
Date: __________________________ Card Limit Requested: $___________
Department: ______________________________________________________________________
APPROVING AUTHORITY
Name & Title: _____________________________________________________________________
Signature: ________________________________________________________________________
E-Mail: ____________________@co.bonneville.id.us Phone: _____________________________
REQUESTED CARDHOLDER INFORMATION
Last Name: ___________________________________ First Name: _______________________
Title: _________________________________________
Address: 605 N. CAPITAL AVENUE
IDAHO FALLS, ID 83402
Phone: ________________________________________
E-mail Address: _______________________________________@co.bonneville.id.us
I accept full responsibility for the Bonneville County Credit Card that will be issued to me and have read and
understand the Bonneville County Policies and Procedures and agree to use the Card in accordance with the terms
and conditions of those policies. I understand that I am personally liable for all unauthorized or improper card charges
that I may incur. If it is determined by my Elected Official, Department Head or the Approving Manager that I have
used this card for unauthorized or improper purposes, I shall reimburse the County in full within ten (10) days. If I
have not reimbursed the County as requested, I understand and agree that the County shall offset all such
unauthorized or improper charges through payroll deduction. Intentional misuse or violation of the Credit Card
Policy will result in disciplinary action up to and including termination and may also result in criminal prosecution.
I understand that this card is valid only while I am employed in this department and that if I transfer to another
department, or my employment is terminated, I must relinquish this card immediately to the Approving Manager,
Department Head, or Elected Official.
Printed Name Signature Date
Date Received Treasurer’s Office: ______________________ Date Sent To Commissioners: _____________________
APPROVED BY: BONNEVILLE COUNTY BOARD OF COMMISSIONERS
_______________________________________ __________________________
Roger S. Christensen, Commissioner/Chairman Bryon Reed, Commissioner
____________________________________ Approved Card Limit: $_________________
Dave Radford, Commissioner
Date A ppr oved: __________________
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