INSTRUCTIONS: Fill-in blocks 1 -- 7 (left-side of form), then mail, fax,
or email this form to the PMF Program Office listed in block 10. Though
payment by charge card is quicker and most efficient, you can use the
PMF Program's OPM Form 1616 for IPAC. Both this version and the 1616 can
be found on the PMF website at http://www.pmf.opm.gov, under "Forms".
Any questions can be directed to the Program Office listed in block 10.
We appreciate your prompt submission. Thank you.

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<tbody>
<tr class="odd">
<td colspan="4"><strong>1. REQUESTING AGENCY REFERENCE:</strong></td>
<td colspan="5"><h2 id="u.s.-office-of-personnel-management">U.S. Office
of Personnel Management</h2></td>
<td colspan="3"><strong>8. FISCAL YEAR:</strong></td>
</tr>
<tr class="even">
<td colspan="4"></td>
<td colspan="5" rowspan="2"><h1
id="presidential-management-fellows-pmf">Presidential Management Fellows
(PMF)</h1></td>
<td colspan="3"></td>
</tr>
<tr class="odd">
<td colspan="4"><strong>2. TOTAL AMOUNT TO CHARGE:</strong></td>
<td colspan="3"><strong>9. OPM/PMF USE ONLY:</strong></td>
</tr>
<tr class="even">
<td colspan="4">$</td>
<td colspan="5"><strong>Program Charge Card Form</strong></td>
<td colspan="3"></td>
</tr>
<tr class="odd">
<td colspan="12"><p><strong>3. PRODUCT/SERVICE TO BE PERFORMED:</strong>
Complete blocks 3 and 3a. before submission.</p>
<blockquote>
<p>The fee of $6,000 is based on agency hiring projections and covers
the cost of recruitment, screening, selection, placement, and PMF
Program Office sponsored events (e.g., job fair, orientation, and
graduation) of the Presidential Management Fellow (PMF). This fee does
not cover travel and per diem expenses associated with attendance at any
PMF-sponsored events.</p>
<p>$6,000 x _____ (Total # of PMFs) = $__________ (Total Amount to be
inserted in block 2, above.)</p>
</blockquote></td>
</tr>
<tr class="even">
<td colspan="12">a. Indicate number and type attachments, if any.
<strong>Use this space to identify the Fellow(s) by full name, class
year, and Entry On Duty (EOD) start date(s):</strong></td>
</tr>
<tr class="odd">
<td colspan="12"></td>
</tr>
<tr class="even">
<td colspan="6"><strong>4. REQUESTING AGENCY (Agency where appointment
was made):</strong></td>
<td colspan="6"><strong>10. PERFORMING AGENCY (OPM):</strong></td>
</tr>
<tr class="odd">
<td colspan="6">a. Agency Name and Address (do not abbreviate):</td>
<td colspan="6">a. Name and Address:</td>
</tr>
<tr class="even">
<td colspan="6"></td>
<td colspan="6"><p>U.S. Office of Personnel Management</p>
<p>Presidential Management Fellows Program</p>
<p>1900 E Street, NW, Room 1425 TAX ID#: 52-1136517</p>
<p>Washington, DC 20415 DUNS# 126536929</p>
<p>ALC: 24-00-0001</p></td>
</tr>
<tr class="odd">
<td colspan="6">b. Program Office Contact Name and Commercial Telephone
Number:</td>
<td colspan="6">b. Program Office Contact Name and Telephone
Number:</td>
</tr>
<tr class="even">
<td colspan="6"></td>
<td colspan="6">Rob Timmins, (202) 606-2674</td>
</tr>
<tr class="odd">
<td colspan="2">c. Program Office Fax Number:</td>
<td colspan="4"></td>
<td colspan="2">c. Program Office Fax Number:</td>
<td colspan="4">(202) 606-3040</td>
</tr>
<tr class="even">
<td colspan="2">d. Internet Email Address:</td>
<td colspan="4"></td>
<td colspan="2">d. Internet Email Address:</td>
<td colspan="4">Rob.Timmins@opm.gov</td>
</tr>
<tr class="odd">
<td colspan="6"><strong>5. COMPLETE "SHIP TO" ADDRESS (if different than
block 4a.):</strong></td>
<td colspan="6" rowspan="8"><p><strong>11. AUTHORITY. (<em>This
agreement is entered into pursuant to the following authority and
incorporates by reference any and all related implementing regulations
and Office of Management and Budget circulars.</em>)</strong></p>
<p>Revolving Fund, 5 U.S.C. 1304(e)(1)</p>
<p>Economy Act, 31 U.S.C. 1535-1536</p>
<p>Intergovernmental Cooperation Agreement Act of 1968, 31</p>
<p>U.S.C. 6501-6508</p>
<p>Government Employees Training Act, 5 U.S.C. 4103-4119</p>
<p>39 U.S.C. 411 (United States Postal Service)</p>
<p>22 U.S.C. 2357(a), (foreign governments)</p></td>
</tr>
<tr class="even">
<td colspan="6">Point of Contact and Telephone Number (if different than
block 6b.):</td>
</tr>
<tr class="odd">
<td colspan="6"></td>
</tr>
<tr class="even">
<td colspan="6"><strong>6. REQUESTING AGENCY FINANCE OFFICE (to be
completed by cardholder):</strong></td>
</tr>
<tr class="odd">
<td colspan="6">a. Cardholder’s Name (enter full name as it appears on
card below):</td>
</tr>
<tr class="even">
<td colspan="6"></td>
</tr>
<tr class="odd">
<td colspan="6">b. Cardholder’s Email Address (enter below):</td>
</tr>
<tr class="even">
<td colspan="6"></td>
</tr>
<tr class="odd">
<td colspan="6">c. Charge Card Number (enter below):</td>
<td colspan="6"><strong>12. OPM\PMF FINANCE CONTACT NAME AND TELEPHONE
NUMBER:</strong></td>
</tr>
<tr class="even">
<td colspan="6"></td>
<td colspan="4" rowspan="2"><p>Rob Timmins, Business</p>
<p>Operations Manager</p></td>
<td colspan="2" rowspan="2"><p>Direct: (202) 606-2674</p>
<p>Fax: (202) 606-3040</p></td>
</tr>
<tr class="odd">
<td colspan="3">d. Charge Card Expiration Date:</td>
<td colspan="3">e. Type of Charge Card:</td>
</tr>
<tr class="even">
<td colspan="3"></td>
<td colspan="3">Visa MasterCard</td>
<td colspan="6"><strong>13. OPM/PMF USE ONLY:</strong></td>
</tr>
<tr class="odd">
<td><p>f. Cardholder’s Phone Number</p>
<p>(commercial numbers only):</p></td>
<td colspan="5"></td>
<td colspan="4"><p>a.</p>
<p>Trans.#:__________________</p></td>
<td colspan="2"><p>b.</p>
<p>Approval#:_______________</p></td>
</tr>
<tr class="even">
<td><p>g. Cardholder’s Fax Number</p>
<p>(commercial numbers only):</p></td>
<td colspan="5"></td>
<td colspan="4"><p>c.</p>
<p>Receipt Sent:______________</p></td>
<td colspan="2"><p>d.</p>
<p>EE HE 1E</p></td>
</tr>
<tr class="odd">
<td colspan="7"><strong>7. AUTHORIZING APPROVAL (REQUESTING
AGENCY):</strong></td>
<td colspan="4">e. PMF Program Project Code:</td>
<td><h3 id="ea3lmx0"> 05EA3LMX0</h3></td>
</tr>
<tr class="even">
<td colspan="5">Cardholder’s Signature:</td>
<td colspan="2">Date:</td>
<td colspan="4">f. GFIS Agreement Number:</td>
<td>g. GFIS Document Number:</td>
</tr>
<tr class="odd">
<td colspan="7"></td>
<td colspan="4">05EA</td>
<td>200</td>
</tr>
</tbody>
</table>