Procurement Cardholder Manual: Individual Card Holder Application

Individual Card Holder Application

Click the button above to download a printable version of this form . In the window that appears, you will be asked, "What do you want to do with this file?" Select "Open it." The form will open in MS word. Please print the form, fill it out and fax to 919-681-9062.

Department Name: ______________________________________________

Paris Administrator (for applicant)__________________________

University Fund Code __ __ __ - __ __ __ __ - NONE - __ __ __ __ __

Please print clearly and completely. Incomplete applications cannot be processed.

Card Holder's Name (First, Middle Initial, Last)

Social Security Number

Mother's Maiden Name (optional-for your security

Position

Home Phone (Area Code, Phone Number) (optional)

Department Mailing Address

Business Manager's Name (Print First and Last)

City, State, Zip Code

Business Manager's e-mail address

Office Phone /Fax Number

Phone:

Fax:

Business Manager's Signature

Date Signed

Card Holder's e-mail address

Chair's/Dean's/Director's or ACOO's Approval (other than Card Applicant) Name (Print First and Last)

Card Holder's Signature

Date Signed

Approving Signature

Date Signed

PLASTIC LAYOUT

Information Reviewed by:________________________			Date: _____________________
Input By: ___________________	Date: _____________		QA By: _____________________	Date: _________