T & E Application and Agreement Form

Travel & Expense Card Application 1505.1.1f

Instructions: Please complete the required fields and submit the signed form to your Access Request Coordinator (ARC) for submission to the Travel Card Office. For assistance completing this form, please contact the Travel Card Office at [email protected].

Accountholder Information

Accountholder Name:

____________________________________________________________________________________________

(Name on card, 21 character limit.)

First Name

Middle Name/Initial (optional)

Last Name

PID:

ONYEN:

_________________________________

Department Number:

UNCCH Email Address:

________________________________________________

Business Phone:

_________________________

NC

Campus Mailing Address:

_________________________________________________________________________________

Street Address

City

State

Zip Code

Monthly Credit Limit:

__________________

(Select the amounts from the dropdown options.)

Additional Comments/Information (Optional)

I agree to use this card for approved purchases only. I further understand that I may be personally liable for any funds misused with this card. In signing below, I attest that I am a permanent employee and at least 21 years of age or older as of the date indicated.

_______________________________________

__________________

Accountholder Signature

Date

Departmental Approval

Department Approver Name:

_________________________________________________________

First Name

Last Name

Department Approver Email Address:

__________________________________________________

Department Name:

______________________________________________

Department Number:

_______________________________________

__________________

Business Manager/Department Head Signature

Date

Taylor Herndon

[email protected]

Hospital Medicine

Travel & Expense Card Accountholder Agreement Form

Instructions: Please complete and submit this form with your T&E Card Application to your Access Request Coordinator (ARC) for submission to the Travel Card Office.

Accountholder Agreement

I, ____________________________________________________ hereby request a Travel & Expense Card.

(Accountholder First and Last Name)

As an Accountholder for the _______________________________________________ Department/Division/Office, I agree to comply with the following terms and conditions regarding my use of the card:

1. I understand that I am being entrusted with a valuable tool, a Travel & Expense (T&E) Card. I will strive to ensure that all purchases shall obtain the best value for the University, shall be solely utilized in the best interests of the University, and shall be strictly for official University of North Carolina at Chapel Hill business.

2. I understand that the University is liable to Bank of America for all charges made on my T&E Card. I further understand that I may be personally liable for the misuse and/or abuse of funds on my card.

3. I agree that I am the only person authorized to make purchases using my T&E Card. Giving the card or account number to another person to make a purchase is not a llowed . I am solely responsible for protecting my T&E Card from misuse/ abuse.

4. I will follow the established terms and conditions for the use of my T&E Card. Failure to uphold the terms and conditions will result in revocation of card privileges and may result in other disciplinary actions, potentially including termination of employment and criminal prosecution, as well as direct repayment or potential paycheck withholding equal to any unauthorized T&E Card charges made by myself.

5. I have read a copy of the Travel & Expense Card Handbook and University Policy on T&E Card Infractions, and I understand the requirements for use of my T&E Card.

6. I agree to return my T&E Card immediately upon request of my Business Manager or Department Head, or upon notice of termination of employment (including retirement) with the University. Upon notice of transfer from my current department within the University, I must notify the Travel Card Office immediately and seek approval to maintain my card from my new Business Manager or Department Head.

7. If my T&E Card is lost or stolen, I agree to notify Bank of America at 1 - 888 - 449 - 2273 (24 hours a day, 365 days a year) and the Travel Card office immediately.

8. [ ]  By checking the box, I expressly acknowledge and agree to comply with all laws, ordinances, codes, regulations, rules, requirements and University of North Carolina at Chapel Hill policies and procedures that are applicable to purchases, including those of federal, state, and local agencies having jurisdiction and/or authority.

_______________________________________

__________________

Accountholder Signature

Date