Fillable Purchasing Card Request Form (Laramie County Community College)

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Purchasing Card Request Form (Laramie County Community College)

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Page 1 of 2
Purchasing Card Request Form
Please type on form.
Name:
Email address:
OcePhone#:         
Last4ofSocialSecurity#:    
Department/Unit:
P-cardApprover/Supervisor:
DefaultBudgetCoding:
P-cardApprover/SupervisorSignature:
Vice-PresidentSignature:
CARDHOLDER ACKNOWLEDGEMENT AND SIGNATURE
IhavecarefullyreadtheforegoingandacknowledgethatIunderstandandagreetoallofthe
abovetermsandcondionsandtoadheretotheP-CardProcedureManualandallapplicable
ContracngandProcurementpolicies,proceduresandguidelines.Furthermore,Iunderstand
thatthefailuretoabidebythetermsandcondionsofthisAgreementmaybecausefor
automacandimmediatelossofP-Cardprivilegesandmayresultindisciplinaryaconupto
andincludingterminaonofemployment.
Signature Date
InialPage2toacceptCardholderAgreement
PRS45309/19
Page 2 of 2
LARAMIE COUNTY COMMUNITY COLLEGE
Department of Administraon and Finance
PURCHASING CARD CARDHOLDER AGREEMENT
ThisPurchasingCard(P-Card),throughthedelegaonofauthorityfromtheVicePresidentofAdministraonand
Finance,representstrustinyoutosafeguardandprotectLCCC’sassetsinaccordancewiththeCollege’spolicies
andprocedure.Therefore,youareauthorizedtocommitfundsonbehalfofLCCCbyuseofthisP-Cardissuedin
yourname.
Asacardholder,IagreetocomplywiththetermsandcondionsofthisAgreement;ContracngandProcurement
ProceduresManual;EmployeePurchasingGuide;ProcurementCardProcedureManual;anysubsequentrevisionsto
thesedocuments;andWyomingDepartmentofWorkforceServices“WageOsetRules,Chapter1,Secon6(b-f).”
1. IacknowledgereceiptoftheP-CardProcedureManualandconrmthatIhavereadandunderstandthe
termsandcondions.IunderstandthatLCCCisliabletoUMBBankforallchargesImakeusingtheP-Card.
IacknowledgethatbyparcipaonintheP-CardprogramIwillnotbesubjectedtoanypersonalcreditreports,
backgroundchecks,orotherpersonalnancialinformaon.
2. IacceptresponsibilityforproteconandproperuseofthecardasoutlinedinthisAgreementandintheP-Card
ProcedureManual.IunderstandthatthecardmaybeusedonlyforauthorizedLCCCbusinessinaccordance
withLCCCpoliciesandprocedures,andthatnopersonalexpensesaretobechargedtothecard.Iauthorize
LCCCtotakewhateverstepsarenecessarytocollectanamountequaltothetotaloftheimproperpurchases
totheextentallowedbylawandinaccordancewithWyomingWageOsetRules.Iunderstandmyuseofthe
P-Cardwillbeauditedandanydiscrepancieswillbeaddressedviawrieninstrument.
3. Iamrequiredtokeepreceipts,packingslips,invoices;reconcileallchargesonamonthlybasis;resolveany
discrepancies;andfollowproperP-Cardsecuritymeasures.
4. IwillreportalostorstolencardimmediatelybytelephonetotheUMBBankCardCenterSecurityDepartment
at1-888-494-5141andtotheP-CardProgramAdministratorat(307)778-1280.
5. IunderstandthatimproperuseoftheP-Cardmayresultindisciplinaryaconagainstme.ShouldIfailtouse
thisP-Cardproperly,IauthorizeLCCCtodeductfrommysalary,orfromanyotheramountpayabletome,an
amountequaltothetotaloftheimproperpurchases.IalsoagreetoallowLCCCtocollectanyamountsowed
byme,evenifIamnolongeremployedbyLCCC.IfLCCCiniateslegalproceedingstorecoveramountsowedby
meunderthisAgreement,IagreetopaylegalfeesincurredbyLCCCinsuchproceedings.
6. IunderstandthatLCCCmayterminatemyprivilegetousetheP-Cardatanymeforanyreason.Iwillreturnthe
P-Cardandallrelatedreceipts,records,andpaperworktotheP-CardProgramAdministratorimmediatelyupon
requestorterminaonofemployment.TheP-Cardprivilegesmayberevokedbasedon,butnotlimitedto,split
purchases,inappropriatepurchases,chroniclackofdocumentaon,personalpurchases,scalmisconductand
non-compliancewithcurrentpoliciesandproceduresasdenedintheP-CardProcedureManual.
7. IacknowledgebymysignaturetothisAgreementthatIhavereceivedformaltrainingintheproperuseofthe
LCCCP-CardandhavereadandunderstandthisAgreement.
InaccordancewithCollegePolicyandProcedures,yourpersonalcardholderaccountabilityincludes:
• Thecardmaynotbetransferredto,assignedto,orusedbyanyoneotherthanthedesignatedcardholder.
UMBBankandLCCCmaysuspendorcanceltheCardholder’sprivilegesatanymeforanyreason.
• AllpurchasesmustbemadebythecardholderonbehalfofandforthebenetofLCCCandtherespecve
department/division.
• TheCardholderwillprotecttheP-Cardfromunauthorizeduse.Thecardholderisresponsibleforproperuse
oftheP-Card,recordcharges,andmustretainallrequiredoriginalreceiptstobesubmiedwiththemonthly
expensereport.
• TheCardholderisresponsibleforfollowinguponerroneouscharges,returns,oradjustmentsandtoensure
propercreditisreceivedontheP-Cardaccount,includingfullcreditformerchandisereturnedtoavendor.
• TheuseoftheP-Cardisforthepurchaseofcommodity,supplyitems,andnon-inventorysingletransacons
andmaynotexceedtherespecvecardlimits.ItisaseriousviolaonoftheP-Cardtodeliberatelypurchase
relateditemsonmulpleoccasionstoavoidthetransaconofcardlimits.
• Purchasesonfederallyfundedaccountsmustbemadeinaccordancewiththerespecvefederalaccount.
• TheCardholderwillremaincompliantwiththeP-CardProcedureManualtoensurethatprohibitedpurchases
arenotmade.
Inialhere_____________
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Purchasing Card Request Form (Laramie County Community College)

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Completed 10 October 2020

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