L JPMORGAN CHASE BANK, N - Indian Health Service
GSA SmartPay2 - Visa Purchase Account Form
To ensure accurate and timely processing please type or print clearly. Incomplete, illegible forms will not be processed.
| New |Cardholder Account| |
|Change (Only Complete Fields To Be Changed) | |- |
|Delete/ Close | | |
| | |- |
| | | |
| | |- |
| | | |
| | | |
|Agency Information Required |
|Agency/Organization Name: DHHS-IHS |
|Company # |Plastic Type |
| |Standard (default) Quasi-Generic Generic |
|Hierarchy Level: |Level 1 (required) |Level 2 |Level 3 |Level 4 |Level 5 |Level 6 |
| |0002 |00004 |30004 |300____ | | |
|Cardholder Information Required |
|Name Line 1 | |Security Identifier # (Required) |
|(19 Characters) | | |
| | | |- | |- | |
|Name Line 2 | |Unique Date i.e. date of hire (Required) |
|(19 Characters) | | |
| | | |- | |- | |
|Address Line 1 | |Unique Passphrase |
|(35 Characters) | |(First 4 Characters Required) |
| | | |
|Address Line 2 | |Work Phone |
|(35 Characters) | | |
| | | |
|City | |State | |Zip Code| | Home Phone |
|(23 Characters) | | | | | | |
| | | | | | | |
|Site ID # | |Employee E-mail | |Employee ID | |
|(Agency Specific) | |(Optional) | |(Optional) | |
|Cardholder Controls – to be completed by A/OPC |
|Credit Limit |$ | Cycle (default) |Single Purchase Limit |$ |
|(Required) | |Weekly Day of the Week | | |
|Transactions Per Day |Unlimited |Transactions Per Cycle |Unlimited |
|Cash Limit (max $500 or 10% |$ N/A |Request Cash Advance Pin |N/A |
|recommended) | |(Yes or No) | |
|Merchant Category Code Groups (at least 1 MCCG required) – Indicate Include or Exclude |
| | | | |
| | | | |
|Approval Required – A/OPC |
| | |Signature: |Date: |
|Prepared By: | | | |
|(Please Print) | | | |
| | |Signature: |Date: |
|Approved By: | | | |
|(Please Print) | | | |
|Forms may be sent by facsimile transmission to JPMC without hard copy follow up provided, however, that JPMC shall be entitled to rely on any unconfirmed, facsimile |
|transmission made by any person or persons JPMC reasonably believes to be acting on behalf of the Corporation as if such notice had been confirmed and the Corporation |
|hereby indemnifies and holds JPMC harmless from any loss, cost or expense, including reasonable attorney's fees, which JPMC may incur or become liable for as a result of|
|such reliance. |
|Bank Use Only | |
|Account Number _ _ _ _ - _ _ _ _ - _ _ _ _ - _ _ _ _ |
| |
Date: ______________
| |
Initials: ____________
| | | |
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