CORPORATE SPONSORED DEPARTMENT TRAVEL CARD APPLICATION Arkansas Department of Finance and Admin. – Office of State Procurement	Dec 2010 TRAV-400D

Section A – Employee Applicant Information

First Name *	Middle Initial	Last Name *
Last 4 Digits of SS Number *	Department Name
Agency Name * University of Arkansas – Cooperative Extension Service
Business Mailing Address * 2301 South University Avenue
City * Little Rock	State * AR	ZIP Code * 72204
Name Embossed on Card *
Email Address * @uaex.edu
Area Code - Business Telephone*	Area Code - Business Fax
Section B – Employee Understanding/Signature (original signatures only) Employee Applicant requests that he/she be issued a U.S. Bank Visa Sponsored Corporate Card. In consideration of this issuance and the use of the U.S. Bank Corporate Card, the Employee Applicant and State agree to be bound by the U.S. Bank Corporate Cardholder Agreement accompanying the card, as amended by U.S. Bank from time to time, for all charges incurred by the use of the card or the related account. Creditor is U.S. Bank National Association ND. I, the undersigned employee, understand that this card is to be used for business travel charges only pursuant to State Travel Regulations found at http://www.dfa.arkansas.gov/offices/accounting/financialManagementGuide/Pages/Subchapter9.aspx, and our policies. The State is liable and responsible for payment of the bill in full. As a cardholder, I agree to make no personal charges on the card. I further understand that if I abuse this privilege, my card may be cancelled by my issuing state entity or the Office of State Procurement.
(Employee Applicant Signature/Date)	(Approving Manager Signature/Date)
(CFO or Agency Head Signature/Date)	(Travel Card Coordinator Signature/Date)
Please send completed application to Financial Services.
Section C – Agency Accounting Information This section is to be completed by the authorized Agency Travel Card Program Administrator.
Name of Company Requesting Issuance of Card University of Arkansas – Cooperative Extension Service
Agency Business Area (4 digits) * 135b	Default Cost Center (6 digits) *	Default General Ledger 729940
Default Internal Order	WBS Element	Funds Res #
Section D – US Bank Information This section is to be completed by State DFA-OSP personnel.
Processing: Agent –4 digits 1930	Company – 5 digits 13160	Division (fund) – 5 digits
Department (org) 4 digits