CARDHOLDER'S Social Security #:   DEPARTMENT Org. Code:
CARDHOLDER'S Phone Number:   Type of Card: Standard :
Travel :

The procurement card is intended for best-judgment (under $5000) purchases. All purchases with this card must comply with the guidelines of the University of Wisconsin-Whitewater's Procurement, Financial Services, and Travel polices and procedures, and with extramural funding restrictions.

Any misuse of the card or other failure to comply with the above procedures will result in the following cardholder consequences: Revocation of card; Disciplinary measures, if appropriate. In addition, if the misuse involves personal transactions, the cardholder is subject to criminal prosecution and held responsible for making full restitution."

As a holder of this procurement card, I agree to accept the responsibility for the protection and proper use of this procurement card as detailed above and in the Procurement Cardholder Manual.

Signature ___________________________________________________ Date _______________
(Card Holder's signature, also type name)

As department chair, and division dean (or 1st and 2nd-line supervisors, as applicable), I approve the issuance of a procurement card to this staff member and assume overall responsibility. Should a cardholder terminate employment with the Universiy, the cardholder's department is required to reclaim the procurement card and return it to Procurement Services.

Signature ___________________________________________________ Date _______________
(Department Chair's or 1st-line supervisor's [as applicable] signature, also type name)
Signature ___________________________________________________ Date _______________
(Division Dean's or 2nd-line supervisor's [as applicable] signature, also type name)
Signature ___________________________________________________ Date _______________
(Procurement Card Manager's [Purchasing Dept.] signature, also type name)
To be completed when card is picked up.

I hereby acknowledge receipt of Procurement
Card #
___________________________________________________ Exp. Date _______________
Signature ___________________________________________________ Date _______________
Sign your card immediately upon receipt

If the card becomes lost or stolen, the cardholder has the responsibility to notify US Bank (800) 344-5696, University Police and Security (262) 472-4660, and Procurement Services (262) 472-1633.