procard application by 609P8J


									                                               Procurement Card Cardholder Account Form
Spending Privileges
Procard to be used for (check one)               Goods/services only                               Travel only                    Both
x New
   Delete/Close             Cardholder Account #                            -               -          -                    AP Use Only

Company Information
Company Name: Northeastern University
Cardholder Information (If the first character of a numeric field is 0, then please precede it with a '
Cardholder Name:                                                                                                    NU ID (9 digits)
(24 Characters)                                        please print
Name Line 2                                                                                                         Date of Birth
(A/P use only)
                                                                                                                    Mother's Maiden Name
Campus Address
(Ex - 320 RP)                                                                                                       Work Phone:
                     Northeastern University

City                 Boston                                                      State          MA                 Zip Code          02115

Banner Index #

Employee ID:                                                                                               Faculty / Staff (circle one)
                                                                                  Applicant NU Email
Applicant Signature:                                                                         Address
Cardholder Controls

Authorizations Per Day 25                     Transactions Per Cycle 800                    Merchant Category Code            AP Use Only

Cardholder Approvals
Dept Head/Immediate Supervisor Approval:
                                      please print name                         Signature


Dept Head/Immediate Supervisor Email:

Senior VP approval:                        please print name                    Signature

ONLY required if requesting ATM privileges                                                                           Date

Accounts Payable Use Only

Approved By:                          please print name                         Signature                            Date

                                 Primary                       Associated                                            Date

* Please do not include 360 Huntington Ave. in the cardholder address
* Once completed and approved please forward to the Accounts Payable office in 320 RP

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