Form: Chset- Trv - Cardholder Setup - Department Of Veterans Affairs

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CARDHOLDER SETUP – Department of Veterans Affairs
Travel - Individually Billed Account – 448622
To ensure timely processing of your application, please make sure to do the following:
1. Complete all fields as they are REQUIRED unless noted as
(optional).
2. Choose the address to which you would like your card shipped.
3. Authorize U.S. Bank to obtain your credit information, sign under the Employee Understanding, and send to your Program Coordinator.
Step 1: APPLICANT INFORMATION
(To be completed by applicant)
Applicant Name: ___________________________________________________
(max. 21 char.)
Social Security Number:
Date of Birth: _____________________
__________________
(9-digits – no spaces or dashes)
(mm / dd / yyyy)
Dept./Office/Agency Name: __________________________________________
(max. 21 char.)
Step 2: CHOOSE CARD DELIVERY ADDRESS
(To be completed by applicant)
Home
-OR- Alternate Address
Complete ONLY if Alternate Address was chosen
Alternate
Home
Address1: ______________________________________
Address1:___________________________________________
(max.35 char.)
(max. 35 char.)
Alternate
Home
Address2: ___________________________________________
Address2: ______________________________________
(max. 35 char.)
(max.35 char.)
City: ______________________________________
City: ______________________________________
(max. 25 char.)
(max. 25 char.)
State: ______
Zip: __________
Country: _______________
State: ______
Zip: __________
Country: _______________
(two char. only)
(5-digits)
(max.10 char.)
(two char. only)
(5-digits)
(max. 10 char.)
Home Phone Number _________________________
Business Phone Number _________________________
(10-digits – no spaces or dashes)
(10-digits – no spaces or dashes)
Business Fax Number _______________________
Business E-mail Address:________________________________________
(optional)
(10-digits – no spaces or dashes)
(max. 60 char)
Employee Understanding/Signature:
Creditor is U.S. Bank National Association ND. Applicant understands that this card is to be used for official travel related expenses.
Applicant understands that the U.S. Bank billing statement is due and payable in full upon receipt. Applicant understands that he/she is
liable to U.S. Bank for full payment of all Charges authorized by applicant, independent of any agreement or program for reimbursement
that may exist between applicant and agency/organization. Information on delinquent accounts may be furnished to consumer reporting
agencies or others who may properly receive that information and you consent to the foregoing.
Applicant acknowledges that all information provided herein is true and correct.
Additionally, (Please CHECK either A. or B. below):
Applicant Signature/Date
A.
I authorize U.S. Bank to obtain credit information in connection with this application.
B.
I do not authorize U.S. Bank to obtain credit information and in accordance your Agency policy.
IBA travel card with restricted limits will be issued.
______________________________
Step3: SEND FORM TO YOUR AGENCY/ORGANIZATION PROGRAM COORDINATOR (A/OPC) FOR COMPLETION
AGENCY/ORGANIZATION INFORMATION
(To be completed by A/OPC)
8 2 0 1
Bank
Company Number
Agent Number _________
Reporting Levels (TBR)
2 3 6 0 0
Level 1
Level 3
Level 2
Level 4
Level 5
Level 6
Level 7
Credit Limit
MCCG
Cash Limit
Default ($5,000)
Default (33% - $410/week)
Default
Restricted ($1.00)
Restricted (33% - $205/week)
Other
Other _________
Other _________
Step 4: AUTHORIZED A/OPC SIGNATURE
Step 5: SUBMIT COMPLETED FORM
A U.S. Bank Travel Card will be issued within 3 days
Signature _______________________________________________________
following the receipt of the completed application
Fax form to: 800-974-0777
Print Name _____________________________________________________
Or mail form to: U.S. Bank Government Services
200 South Sixth St. EP-MN-L25C
Phone ______________________
Minneapolis, MN 55402
Questions?
Fax ________________________
Date Submitted _____________________
Call Customer Service at 888-994-6722
Form: CHSET- TRV (11/10)
1 of 1

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