Last updated: 12-Mar-2012
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USNH Purchasing Card Application


* indicates required fields

* Request Type (Defined)

Individual Account
Departmental Account
Sponsor Account
Convenience Checkbook Account - State number of books needed

Cardholder Information
*First Name: Middle Intial: *Last Name: *USNH ID Number:
*Mother's Maiden Name: *Date of Birth: *Campus Phone:
Cardholder Campus Address: (For use as verification/billing address)
Provide the Department Name, Building, Room, Street Address, City, State, Zip
*Address:
*Campus:

Card Information
*MCC Code: (Defined) Card Description (Defined):
* Cardholder Campus Email Address:
*Max Dollars per Transaction: *Max Number of Transactions per Day:
*Max Dollars per Month: *Max Number of Transactions per Month:
If the above limits do not meet your needs, leave blank and email the Campus Card Administrator.

Business Unit Information
Account Manager *First Name: *Last Name: *Banner Username:
Business Manager *First Name: *Last Name: *Banner Username:
Default Account Information *Fund: *Org: *Account: Activity (optional): *Responsible Org

Sponsor Information
A Sponsor is required if the cardholder has a non-status appointment. Sponsor must be a benefits-eligible employee. Sponsor must sign the Sponsor Authorization section of the application.

*All fields are required if a Sponsor is applicable.

First Name: Last Name: USNH ID Numberr:
Date of Birth: Mother's Maiden Name: Campus Phone:


Signature Page: Type the name and date for each section below and then follow the instructions at the end or verify accuracy of the form now, and then print and complete the signature page manually.

Cardholder Authorization

I request a purchasing card be issued to me. I agree to comply with all institutional policies and procedures regarding proper use and safekeeping of the card and understand that goods are to be purchased solely for institutional purposes. I agree that failure to comply with these conditions may result in the withdrawal of the privilege of using the purchasing card. I further understand that purposeful, fraudulent or negligent behavior on my part regarding use of the card will be considered serious misconduct and may result in disciplinary action up to and including termination or legal action, as stipulated in the USNH Cardholder's Guide.

Signature Name Date

Sponsor Authorization (Required if cardholder has a non-status appointment)
I hereby authorize a purchasing card be issued to the individual whose name appears above. Additionally, I authorize this person to make institutional purchases on my behalf, and I will review those purchases monthly. I agree to notify immediately my business manager when the above referenced individual either terminates or separates from this department or whenever a purchase made by this person appears not to meet USNH policies.

Signature Name Date

Business Unit Authorization
I hereby authorize a purchasing card be issued to the individual named above. I understand that the business unit will be held responsible for the proper use of the card including ensuring that all charges are posted to the appropriate accounts and maintaining the required records for all card transactions.

Signature Name Date


DO NOT COMPLETE THIS SECTION UNTIL CARD HAS BEEN RECEIVED AND TRAINING HAS TAKEN PLACE


Cardholder Acceptance
I certify that I have read and understand the policies and procedures on the appropriate use and handling of the purchasing card and do hereby agree to comply with them. I also agree to surrender this card to my business unit account manager or business manager upon request or upon my termination/separation from this business unit.

Signature Name Date

Witnessed by Campus Card Administrator:

Signature Name Date

Instructions for Submitting Application:
  1. Click the "Print" button
  2. Complete the signature page obtaining all required signatures
  3. Mail or fax application to the appropriate campus below:


UNH/GSC/UNHM/USNH KSC PSU
USNH Financial Services
Dunlap Center
25 Concord Road
Lee, NH 03861
Fax: 603-862-0919
Purchasing & Contract Services
229 Main Street
Keene, NH 03435
Fax: 603-358-2495
Accounts Payable
17 High Street, MSC #13

Plymouth, NH 03264
Fax: 603 535-2789