- Print application from the Controller's Office web site.
- Forward completed and signed application to Abby Bienkowski in the Controller's Office.
- NO application will be processed without a signed copy of the appropriate
Cardholder agreement.
Click on the following link for the agreement. American Express Cardholder Agreement
Cardholder Name: ________________________________________
(As it should appear on card, maximum 20 characters, including spaces)
Billing Address:
PO Box 67
Williamstown, MA 01267
Home Street Address: _______________________________________________________
(20 characters, including spaces, if different than billing address)
City:__________________ State:_______ Zip Code:________
Cardholder Social Security Number:_________________________________
Home/Personal Phone Number:________________________________________
Business Phone Number:_____________________________________________
Employee's Signature:___________________________________ Date:__________________
(By signing above I indicate my acceptance of the terms and conditions of the Agreement)
Agreement: Company and the Applicant (a) request that a Corporate Card be issued to the Applicant on the Company's account, (b) authorize the receipt and exchange of credit information on the Company and the Applicant, (c) agree to be bound by the Agreement sent with the Card and by the Agreements covering Corporate Card related programs in which the Applicant is enrolled, and (d) agree that the Corporate Card will be used for business or commercial purposes only. The Applicant (a) authorizes American Express to notify the Company if this application is declined or if spending restrictions are applied to the Corporate Card, and (b) agrees to be liable for payment to American Express of all amounts charged to the Corporate Card.
Please complete the following
PeopleSoft Account string to be charged for AMEX expenditures:
Fund:____________ Department ID:______________________ Project:______________(if applicable)
Where do you want your AMEX Reconciliation Report sent:
Name of Building and Department:_______________________________________________
Person who should receive your AMEX Reconciliation Report:
Name:_________________________________________________________