Montana State University Purchasing Card
Individual Card Application
Please print clearly and completely.
Cardholder’s Name (First, Middle Initial, Last)
Employee ID Number (0 + GID#)
Opt In ( Receive E-Mail Notifications of Charges)
___ Cardholder
___ Account Manager
___ Business Manager
Department PO Box (For Monthly Statement Delivery)
1500 University Drive
City, State, Zip Code+ 4 Digits
Billings, MT 59101
Phone number (Include Area Code)
US Bank Use In case of Fraud
ORGN # of Reporting Department
Department Name: ____________________________________________
Department Account Manager: __________________________________
Depart Back-up Account Manager: _______________________________
Department Head: _____________________________________________
_________________________________ _____________
Signature Date
_________________________________ _____________
Signature Date
_________________________________ _____________
Signature Date
I acknowledge that I have read and understand the Purchasing Card Manual and will follow all requirements. Non-adherence
to any of the procedures outlined in the manual will result in revocation of the individual cardholder privileges and may result in
revocation of all departmental credit cards. I understand that my use of the University’s credit card for personal purposes or by
loaning my University credit card to an unauthorized individual will result in discipline, up to and including dismissal from
employment. I hereby authorize the University to hold my final paycheck until I have returned the credit card to my supervisor. I
also authorize the University to withhold from my paycheck any amounts charged to me for any personal or non-reimbursable
use.
Credit Card Applicant’s Signature________________________________________________Date_____________
Monthly Spending Limits
$_________________
(5,000 Recommended)
If requesting a monthly limit > $5,000
please describe how it meets your business
needs. (Attach Documentation)
Single Per Purchase Limit
$____________________
(3,000 Recommended)
___University Expenses
___University Travel Expenses Only
(airplane, hotel, car rental, gas,
shuttle)
___Rental Car/Gas Only
Campus Location: MSU Bozeman MSU Billings Great Falls College MSU MSU Northern
MSU P-Card Program Administrator
Phone: (406) 994-5727
Fax: (406) 994-1954
UBS Program Administrator
UBS Program Administrator’s Signature____________________________Date_________________________
Revised 1/14/14
