For State of Texas Use Only

(A) Check One:

 New

(B) Corp #      

 Change (Only complete fields to be changed)

 Delete/Close

Cardholder Account #

      -       -       -       (16 digits)

(C) State Of Texas Agency / University / Co-Op Information

Agency / University / Co-Op Name: ­­­­­­­­­­

Brazosport College District

Agency / University /Co-Op Code:

J0200

(D) Cardholder Information (Please Print Required Information)

Cardholder Name

(24 Characters)

Brazosport College

Social Security #

XXX -XX -     

Email Address

Department Name

(35 Characters)

Work Phone

(     ) -      -      

Address Line 2

(35 Characters)

500 College Drive

Home Phone

(     ) -       -      

City

(23 Characters)

Lake Jackson

State

Texas

Zip Code

77566

Default Internal Audit Code:      

(E) Reporting Hierarchy Level Numbers  (Required Information)

Level 1 Number     

Level 2      

Level 3     

Level 4     

(F) Cardholder Controls (Required unless specified)

Credit Limit (CSL)

Single Purchase Limit (SPL)

Authorizations Per Day

Transactions Per Cycle

MCC Group

(Merchant Category Code Group)

(G) Cardholder Approvals

Program

Administrator:

Date

Signed

Verification      

 ID Number

Departmental/Supervisor’s Signature:

(OPTIONAL based on

Agency’s internal policies)

Date

Signed

Applicant:  Please Complete form and forward to: (Insert Program Administrator’s instructions for cardholder to send application.)

(H) Bank Use Only

Account Number    ___ ___ ___ ___ - ___ ___ ___ ___ - ___ ___ ___ ___ - ___ ___ ___ ___

Verification ID# Verified:

Date:

Initials: