7900823234WorkOrder.pdf
PDF 110 KB Posted
- Attached to
- American Express ® Card Acceptance (Statewide)
- Contract number
- Not on record
- Issued by
- New York
About this file
This document is a Work Order Form (Appendix G) for American Express® Card Acceptance services under Contract #PS69501, which is part of Group 79008 - American Express® Card Acceptance (Statewide). The contractor is American Express Travel Related Services Company, Inc., with merchant services handled through their Phoenix, Arizona office (PO Box 53773, Phoenix, AZ 85072). This appears to be a statewide contract managed through OGS Procurement Services, serving as an Electronic Value Transfer Administrator (EVTA) program for government entities.
The contract provides American Express card acceptance services for authorized users, requiring completion of program details including authorized user information, payment program names, and division details. The work order form addresses administrative requirements such as invoicing and chargeback contacts, and includes provisions for convenience fees (merchant managed) and service fees (third-party managed), with options to describe fee computation methods. The form also accommodates pre-existing merchant accounts by allowing entities to list current CAP (Customer Account Profile) or Merchant Identification Numbers (MID) with American Express. Final approval requires OGS Procurement Services EVTA authorization, and the form tracks whether applicants have previous EVTA-2 work orders with the same procurement services and American Express arrangement.
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Other files
| File | Type | Posted |
|---|---|---|
| 7900823234pm.pdf | ||
| 7900823234MerchantReg.pdf | ||
| 7900823234Pricing.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 .