ࡱ> 352 bjbjAA *"++ `````ttt8$trtttttt$i~```F``rrP*PPJ ^0`k &: LOUISIANA TECH UNIVERSITY STATE LIABILITY TRAVEL CARD/CBA PROGRAM CARDHOLDER ENROLLMENT FORM REVISED 11/11 ( NEW ( CHANGE CARDHOLDER ACCOUNT # ________________________________ (last eight digits only) ( DELETE - CARDHOLDER ACCOUNT # _________________________________ (last eight digits only) -------------------------------------------------------------------------------------------------------------------------------------------- Section I: To be completed by Cardholder: Cardholder Name:_________________________________________________( maximum of 26 spaces) Division: ______________________________________ Department: ______________________________ Departmental Account Number (or Grant Number): __________________________________ (Card transactions will be charged to this account) Statement Billing Address: __________________________________________________ (Department Address) __________________________________________________ City, State, & Zip: __________________________________________________ Phone #: _________________________________E-mail Address:__________________________________ Supervisor/Reviewer Signature: ________________________________________________ (New account requires Dean or Vice President signature) -------------------------------------------------------------------------------------------------------------------------------------------- Section Two: To be completed by the Office of the Comptroller: Overall Card Limit: ______________________________ Single Transaction Limit: ________________________ (Max $5000) Number of Purchases Allowed per month: ___________ (9th to 8th each month) Spending Limit per Cycle: _________________________ (9th to 8th each month) ACCOUNTING CODE: __________________________________________________ HIERARCHY: ________________________________________________________________________ Select appropriate group name from list provided by State Travel APPROVED BY: ____________________________________ DATE:_______________________________ -------------------------------------------------------------------------------------------------------------------------------------------- NOTE: This form is to be completed by the cardholder, approved by the supervisor/reviewer and forwarded to the Office of the Comptroller, with the completed cardholder agreement, for processing. Please send to Office of the Comptroller, Campus Box 19 or FAX to (318) 257-2234. 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