CENTRAL CONNECTICUT STATE UNIVERSITY
Purchasing Card Application Form
New Account
Change (only complete fields to be changed)
CARDHOLDER INFORMATION [PLEASE PRINT-
ALL GRAYED AREAS TO BE COMPLETED BY APPLICANT]
Cardholder’s Name [up to 24 characters] Department Work Phone Number
860.832.
*This information is needed for identification purposes only and will not be reflected on personal credit history.
REPORTING HIERARCHY CONTROLS [Please leave this section blank]
Budget Authority Signature Banner Index
Application is P-Card Member Services Coordinator Signature Date
Approved Denied
Cycle Spending Limit - $ 10,000
Maximum Transactions/Day – 20
Single Purchase Limit - $2,500
Maximum Transactions/Cycle - 100
Cardholder’s Signature Date
DEPARTMENTAL APPROVAL
E-mail Address
ccsu.edu
MCC Group [Merchant Category Control Group] Check One
Include
Exclude
Supervisor’s Signature (only required if you are both the cardholder and budget authority for
your department) Date
Social Security Number* Date of Birth
[last 4 digits only]
Mother’s Maiden Name or Password
