DOA-3584PurchasingCardApplicationandUseAgreement.docx

Wisconsin Department of Administration S State Bureau of Procurement Division of Enterprise Operations

DOA-3584 (R 12/2022)

Purchasing Card Application and Use Agreement

Please Complete and Submit to the Agency P-card Administrators Employment Status (circle one) FTE or LTE Employee IAM

Cardholder Name (as shown on payroll) Division/Work Unit Credit Limit

PO Box or Street Address (Work address for billing statements)

City State Zip Work Phone Number

Email

The Purchasing Card is intended for best judgment purchases (through $5,000). Purchases made with this card must comply with the Department of Administration and agency procurement policies and procedures as stated in the State Procurement Manual, the State Accounting Manual, and the agency Purchasing Card User Manual.

The Purchasing Card MAY NOT be used for cash advances (ATM machines) or to purchase non-business personal items and services. Inappropriate charges or charges without proper supporting documentation may require reimbursement to the sponsoring agency by the cardholder.

If the card becomes lost or stolen, the cardholder MUST IMMEDIATELY NOTIFY US Bank and the Agency P-card Administrators.

When a cardholder terminates employment with the agency or transfers to another agency/division, the sponsor division shall destroy the Purchasing Card and notify the Agency P-card Administrators.

Non-adherence to any of the above procedures may result in revocation of individual cardholder privileges and potential discipline and may result in the revocation of all sponsor division and/or agency Purchasing Cards.

As an applicant/cardholder of a State of Wisconsin Purchasing Card, I assume the responsibility for the protection and proper use of this card as detailed above in the State Procurement Manual, the State Accounting manual, and the agency Purchasing Card User manual.

Applicant/Cardholder Signature Date Signed (mm/dd/ccyy)

As the Employee HR Supervisor of the Applicant/Cardholder, I assume the responsibility for reviewing the use of this card by the cardholder ensuring it is protected and properly adhered to the State Procurement Manual, the State Accounting Manual, and the agency Purchasing Card User Manual.

Employee Supervisor Signature Date Signed (mm/dd/ccyy)

As the Sponsoring Division Authority, I approve the issuance of a State of Wisconsin Purchasing Card to the above-named employee.

Sponsoring Division Authorized Signature Date Signed (mm/dd/ccyy)

Agency Financial Manager Date Signed (mm/dd/ccyy)

Agency P-Card Administrator Signature Date Signed (mm/dd/ccyy)

Note: You must identify the ChartFields and Proxies on Page 2 of this application

To Be Completed by the Cardholder:

Provide justification below if p-card is for a LTE (required for LTE employees only).

CHARTFIELD

Provide the default ChartField for the P-Card.

For split funding, the Agency P-Card Administrator must set up a speed chart in STAR and percentages must equal 100%.

GL UNIT

BUD REF

FUND

APPROPRIATION

DEPARTMENT

PROGRAM

OP UNIT

PRODUCT

PC BUS UNIT

PROJECT

ACTIVITY

SOURCE TYPE

CATEGORY

SUBCATEGORY

Role Assignment In the Employee Name section, indicate the person(s) that shall be connected to your P-Card for the purposes of performing the functions as described for each role. Contact your Agency P-Card Administrators for assistance as needed.

AGENCY P-CARD RECONCILER (required) Reconciles transactions and updates distributions. Can be the cardholder OR a proxy user who reconciles on behalf of the cardholder.

AGENCY P-CARD REVIEWER (optional) Reviews transactions but does not have ability to update transactions (i.e. an auditor). Do not assign the Agency P-Card Administrator to this role.

STATE P-CARD MAINTAINER

Corrects errors for transactions that fail to load from the bank file. Agencies must add these admins to all cards.

Penny Lawler Leann McGowen Cheryl Edgington

This document can be made available in alternate formats to individuals with disabilities upon request.

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