New York State Procurement Card Program Maintenance Form

PART I: CARDHOLDER INFORMATION
Company Name:


Date:


Cardholder Account #:


Billing Address:


Cardholder Name:


City/State/Zip:




PART II: ACCOUNT MAINTENANCE (Check all that apply)

              A:      [    ]      NAME CHANGE (Name is limited to 20 letters)
Cardholder Name as appears:


Cardholder Name as should appear:



The undersigned hereby requests a name change be effected and a Procurement Card be issued herein and renewed and replaced until the undersigned gives notice to cease. By requesting the name change, the undersigned understands that Citibank ® will cancel any outstanding Procurement Cards issued in the former name. The undersigned further agrees to destroy any cards they may hold under the former name.


Cardholder's Signature: ________________________________________


              B:      [    ]      ADDRESS CHANGE (Address limited to 38 letters)
Current Billing Address:


New Billing Address:



              C:      [    ]      CARD REPLACEMENT
[  ]

Stolen
[  ]

Lost
[  ]

Not Received
[  ]

Embossing
Error
[  ]

Mutilated
[  ]

Other

This notification to Citibank ® must be made verbally by the cardholder by calling (1-800 and completing this form. Failure to comply with this notification process may result in the cardholder becoming personally liable for the fraudulent use of the card.

Comments

Date New Card Received

PA
Initials



              D:      [    ]      CANCELLATION / REINSTATEMENT
[  ] Cancellation [  ] Reinstatement
Reason




              E:      [    ]      MONTHLY TRANSACTION LIMIT
Current Monthly Transaction Limit:

New Monthly Transaction Limit



              F:      [    ]      INDIVIDUAL TRANSACTION LIMIT
Current Per Transaction Limit:

New Per Transaction Limit




              G:      [    ]      CURRENT TOTAL DOLLAR LIMIT
Current Total Dollar Limit:

New Total Dollar Limit:




PART III: APPROVAL PROCESS

              Completed by Cardholder's Supervisor:
Approved by:

Title:

Signature:

Date:


When complete the cardholder's supervisor should keep a copy of this form for their records and forward the original to the Campus Procurement Card Administer for processing. The Program Administrator will review and sign, if approved. The original will then be forwarded to Citibank ® for processing.

Completed by Citibank ® Program Administrator:

Signature: ____________________________ Date: ___________________



[   ] APPROVED

[   ] DISAPPROVED

Reason for Disapproval: __________________________________________________________


_______________________________________________________________________________