Purchasing PC04
BTA Card Change Request Form
This form is used by BTA Cardholders to request a change in their BTA Card balance limit, to remove or add MCC code
restrictions, and to cancel the card should they no longer need it.
Cardholder Information:
Full Name: ______________________________________________________________
Last 4 digits of BTA Card # ______________
Change Request:
Date of Request: ____________________
Current Monthly Limit: $15,000
Requested Monthly Limit: _______________
Explanation for the Increase: _________________________________________________
_________________________________________________________________________
Is this above request a permanent request or a temporary Request?
Permanent
Temporary
If the request is permanent, please explain why:
__________________________________________________________________________
__________________________________________________________________________
Cancelling a BTA Card:
Request to Cancel BTA Card? Yes No
BTA Card receipts and statements are kept with Office Administrator for Auditors: Yes No
Change Request Approval:
Your approval of the form and confirms that all information is accurate. Approval must either be with written
signature of official digital signature.
Cardholder: ______________________________________________ Date: _____________
Department Head/Dean: ___________________________________ Date: _____________
Procurement Office Approval:
Purchasing Card Administrator: ________________________________ Date: ___________
Procurement Manager: _______________________________________ Date: ___________
Administrator Notes: _________________________________________________________
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