Name New Program printed name. – Administrator’s Role Role the designated individual will perform (Primary or Backup). – Effective Date Date Program Administrator is to be added. – Office Overnight Delivery Address Complete address including city, state and zip code. – Office Mailing Address Complete address for USPS delivery, if different from above. – Phone Telephone number (including extension) and fax number (including area code). – E-mail Address Current E-mail address. – New Program Signature New Program signature. Administrator’s – Administrator’s E-mail Address New Program E-mail address. Supervisor’s – Administrator’s Supervisor’s Delete Program Administrator: This information pertains to the individual you are requesting to be deleted as a Primary Program Administrator or as a Backup. Please complete a separate form for each individual Program Administrator. Name of Program Administrator to Be Deleted Program printed name. – Administrator’s Role Role the designated individual performed (Primary or Backup). – Effective Date Date Program Administrator authorization is to be deleted. – Is the person listed to be deleted a cardholder? If YES to #4, does the card need to be cancelled? This section is for DOA purposes only. For DOA Office Use Only: Commonwealth of Virginia Agency Airline Travel Card ALL INFORMATION REQUIRED Please print clearly and completely. Incomplete applications can not be processed. Name (First, Middle Initial, Last) Agency Name Cardholder’s Mailing Address Agency # City, State, Zip Code Business Phone Number ( ) E-mail Address Date of Birth (mm/dd/yy) Cardholder Signature Date I agree and understand that at least annually the activity on all Agency Airline Travel Cards (ATC) will be reviewed to ensure limits are appropriate for the usage. I will provide written recommendations regarding any limit changes. card’s I further certify that I will review and approve this transactions and supporting documentation on a monthly basis. cardholder’s
Name – New Program Administrator’s printed name. Role – Role the designated individual will perform (Primary or Backup). Effective Date – Date Program Administrator is to be added. Office Overnight Delivery Address – Complete address including city, state and zip code. Office Mailing Address – Complete address for USPS delivery, if different from above. Phone – Telephone number (including extension) and fax number (including area code). E-mail Address – Current E-mail address. New Program Administrator’s Signature – New Program Administrator’s signature. Supervisor’s E-mail Address – New Program Administrator’s Supervisor’s E-mail address. Delete Program Administrator: This information pertains to the individual you are requesting to be deleted as a Primary Program Administrator or as a Backup. Please complete a separate form for each individual Program Administrator. Name of Program Administrator to Be Deleted – Program Administrator’s printed name. Role – Role the designated individual performed (Primary or Backup). Effective Date – Date Program Administrator authorization is to be deleted. Is the person listed to be deleted a cardholder? If YES to #4, does the card need to be cancelled? For DOA Office Use Only: This section is for DOA purposes only. Commonwealth of Virginia Agency Airline Travel Card ALL INFORMATION REQUIRED Please print clearly and completely. Incomplete applications can not be processed. Cardholder’s Name (First, Middle Initial, Last) Agency Name Mailing Address Agency # City, State, Zip Code Business Phone Number ( ) E-mail Address Date of Birth (mm/dd/yy) Cardholder Signature Date I agree and understand that at least annually the activity on all Agency Airline Travel Cards (ATC) will be reviewed to ensure limits are appropriate for the card’s usage. I will provide written recommendations regarding any limit changes. I further certify that I will review and approve this cardholder’s transactions and supporting documentation on a monthly basis.