7900823234WorkOrder.pdf
PDF 110 KB Posted
- Attached to
- American Express ® Card Acceptance (Statewide)
- Contract number
- 23234
- Issued by
- New York
About this file
This document is a Work Order Form for the Electronic Value Transfer Administrator (EVTA) under Group 79008, a Statewide American Express® Card Acceptance contract. The contract is between American Express Travel Related Services Company, Inc. and the New York Office of General Services (OGS) Procurement Services, with contract number PS69501. The form is designed to be completed by an authorized user seeking to establish or modify American Express card acceptance services.
The Work Order Form provides a template for detailing program specifics, administrative requirements, and unique terms and conditions for American Express card acceptance. It includes sections for capturing contractor and authorized user information, invoicing and chargeback contacts, and options for convenience and service fees. The form allows for listing pre-existing merchant accounts and provides a signature section for OGS Procurement Services approval. While specific pricing and detailed service terms are not explicitly outlined in this document, it serves as an administrative tool for implementing and tracking American Express card acceptance across state agencies and authorized users.
View the file
Other files
| File | Type | Posted |
|---|---|---|
| 7900823234pricing.pdf | ||
| 7900823234MerchantReg.pdf | ||
| 7900823234Pricing.pdf | ||
| 7900823234pm.pdf | ||
| 7900823234HowtoUse.pdf | ||
| 7900823234ra.pdf |
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Text version
GROUP 79008 – American Express® Card Acceptance (Statewide) PAGE 1 of 2
23234 American Express Travel Related Services Company, Inc. (PS69501)
Appendix G – Work Order Form
Work Order Form Electronic Value Transfer Administrator
AMERICAN EXPRESS® CARD ACCEPTANCE
WITH
AMERICAN EXPRESS TRAVEL RELATED SERVICES COMPANY, INC.
CONTRACT #PS69501
Section 1: Program Details
Date: Program Plan Application
Approval #:
Program Plan Application Approval Date:
Authorized User Name: Payment Program Name:
Division Name:
Contractor Information:
American Express Travel Related Services Company, Inc.
Merchant Services
PO Box 53773
Phoenix, AZ 85072
Authorized User Information:
Name:
Title:
Email Address:
Phone Number:
Location of Service Address:
Expected Start Date of Servicing: Did you have a previous EVTA 2 Work Order
Form with OGS Procurement Services and
American Express?
☐ Yes ☐ No If yes, please list your previous OGS Procurement Services
EVTA-2 approval #:
GROUP 79008 – American Express® Card Acceptance (Statewide) PAGE 2 of 2
23234 American Express Travel Related Services Company, Inc. (PS69501)
Section 2: Administrative Requirements Checklist
Invoicing: (Billing statement contact: name/ address/ phone number):
Chargebacks: (Contact: name/ address/ phone number):
Section 3: Unique Terms and Conditions
Convenience Fees:
(merchant managed)
☐ Yes ☐ No If yes, describe how the fee will be computed:
Service Fees:
(3rd party managed)
☐ Yes ☐ No If yes, describe how the fee will be computed:
Section 4: Pre-existing merchant accounts (CAP/ MID #’s)
List pre-existing CAP or Merchant
Identification Number
(MID) with Amex
Section 5: Signature Section
OGS Procurement Services EVTA Approval
| Date: |
| Program Plan Application Approval: |
| Program Plan Application Approval Date: |
| Authorized User Name: |
| Payment Program Name: |
| Division Name: |
| Expected Start Date of Servicing: |
| If yes please list your previous OGS Procurement Services: Off |
| Invoicing Billing statement contact name address phone number: |
| Chargebacks Contact name address phone number: |
| Yes No If yes describe how the fee will be computed: |
| undefined: Off |
| undefined_2: Off |
| Yes No If yes describe how the fee will be computed_2: |
| undefined_3: Off |
| undefined_4: Off |
| List preexisting CAP or Merchant Identification Number MID with Amex: |
| OGS Procurement Services EVTA ApprovalRow1: |
| Title: |
| Email Address: |
| Phone Number: |
| Location of Service Address: |
| Name: |
| EVTA-2 approval #:: |
File details come from the government source that posted it. Updated .