PURCHASING DEPARTMENT
LACARTE PURCHASING CARD APPLICATION
Cardholder’s Name: ________________________________________________
Social Security #: ___________________ Job Title: _________________
Department Name: _________________________________________________
Department Codes (List all codes you are budgeted to use) (Use 2
nd
page if needed):
________________________ _______________________ _______________________
________________________ _______________________ _______________________
Cardholder Address for Department (PO Box): _______________________
City, State and Zip Code: ________________________________________
Business Phone #: ________-_________-____________
LA Tech Email Address: ________________________________________
Single Transaction Limit Requested: $1000.00 $5000.00
Monthly Limit Requested (Circle 1): $3000.00 $8000.00 Other: ________________
Cardholder’s Signature: ____________________________________ Date: ____________________
Cardholder’s Approver (Must be 1 level higher) : __________________________________________
Approver’s Signature: _____________________________________ Date: ____________________
(Note: If department code listed above is a grant, Office of Sponsored Projects is the approver.)
Approver’s Email: ________________________________________ Phone #: __________________
Comptroller’s Approval: ___________________________________ Date: ____________________
Section1:Tobecompletedbycardholder andapprover.
Section2:TobecompletedbythePurchasingDepartment(ProgramAdministrator):
Iapprovetheabovenamedcardholder’srequestforaPurchasingCard:
Signature:__________________________________________Date:________________________
