Application
Applicant name: ______________________________________________
De
partment Name: ____________________________________________
Default GL Acct. Number: _________-________________-___________
*M
onthly Credit Limit: $________________________________________
Employee ID#:______________Date:________________
Work Phone: (_______)____________________
Applicant SS#__________________(Last 4 digits)
Single Transaction Limit: $________________________
* Can not be greater than the number of transactions per month, times the single transaction limit, and,
should not be greater than the Department budget for the default account.
Other: _____ Per Day / _____ Per Month
1. Department Head ___________________________________________ Date:_______________________
Print name ____________________________________________________
2. Dean (if applicable) __________________________________________ Date:_______________________
Print name_____________________________________________________
3. Area V.P.___________________________________________________
Date:_______________________
Print name_____________________________________________________
Program Coordinator: ________________________________________
Date:_______________________
Print name____________________________________________________
Approving Individual__________________________________________
Date:_______________________
Print name____________________________________________________
Approving Individual__________________________________________
Date:_______________________
Print name ____________________________________________________
Cardholder_____________________________________________________
Date:_______________________
Program
Coordinator ___________________________________________ Date:_______________________
Updated November, 2015
I acknowledge receipt of the Monmouth University Purchasing Card and the Monmouth University Purchasing Card Policy and
Procedures document. I confirm that I have read, understand, and will comply with the terms of this policy and procedures document. I
agree that my use of the card will be for University business only and that I am the only user of the card. I will return my Card to Human
Resources or the Program Coordinator at my termination or upon request. I understand that the University may terminate my privilege
to use this card at any time and for any reason including misuse of the Card. I further understand that I must document the expenses
charged to my Card within 20 business days after my receipt of my monthly statement. If I fail to do so, I authorize the University, at its
option, to deduct the amount of the undocumented or unallowable charges from my pay.
Default # of Transactions: 5 Per Day / 20 Per Month
Would you like this card set up to be used on the W.B. Mason On-Line Account?
Yes No
App
licant Signature:____________________________________________
For Controller’s Office Use Only
Please obtain the following three signatures before returning this form to the Controller's Office
**** To Be Signed By Cardholder When Card Is Issued ****
Works
Co. Prop.
E-mail
