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### CITIBANK^®^ GOVERNMENT TRAVEL CARD (INDIVIDUALLY BILLED ACCOUNT) SETUP FORM

NOTE: The Agency/Organization Program Coordinator (AOPC) should complete
this form with the required information input from the Cardholder.

**SECTION I [INSTRUCTIONS (Please also see "Important Information" at
the top of the next page.)]{.underline}**

1.  To add a new account, Cardholder completes Section IV and signs in
    Section V; AOPC completes Sections II, III, VI and VII. The AOPC
    signs in Section VII. **[Please use font size 12 when filling out
    this application]{.underline}**.

2.  Maintain a copy in the Cardholder and Agency/Organization Program
    Coordinator's files.

3\. Fax completed form to your Agency / Organization Program Coordinator

**SECTION II [REPORTING PARAMETERS - COMPLETED BY AOPC]{.underline}**

\*Reporting Hierarchy: (1) \_\_\_\_\_\_\_\_\_\_ \_\_\_\_\_\_\_\_\_\_\_
\_\_\_\_\_\_\_\_\_\_\_ \_\_\_\_\_\_\_\_\_\_\_\_ \_\_\_\_\_\_\_\_\_\_\_
\_\_\_\_\_\_\_\_\_\_\_ \_\_\_\_\_\_\_\_\_\_\_

\*Processing Unit ID #: (2) \_\_\_\_\_\_\_\_\_\_ (maximum 5 characters)

**SECTION III [PLASTIC TYPE- COMPLETED BY AOPC]{.underline}**

\(3\) Government Standard \_\_[X]{.underline} Quasi-Generic Generic

**SECTION IV [CARDHOLDER INFORMATION]{.underline}** (Please Print)

[(4)]{.underline}

\***First** Name of Cardholder \***Middle** Initial \***Last** Name
(maximum 20 characters)

[(5) ( )]{.underline}

\*Agency/Organization Name (maximum 24 characters) \*Home Phone

[(6) ( )]{.underline}

4th Line Embossing \*Business Phone

[(7) ( )]{.underline}

\*Home Mailing Street Address Line 1 (maximum 36 characters) Fax Number

**Your statement is mailed to this address; PO Boxes cannot be used.**

[\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_(8)\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_]{.underline}

Home Mailing Street Address Line 2 (maximum 36 characters) \* Social
Security Number

\*City \*State \*Zip Code Country

[(9)]{.underline}

\*Business Address Line 1 (maximum 36 characters)

[(10)]{.underline}

Business Address Line 2 (maximum 36 characters) \*Verification
Information (Mother's Maiden Name)

\*City \*State \*Zip Code Country

[(11) (12)]{.underline}

E-mail Address \*Date of Birth (mm/dd/yy)

**SECTION V (13) [CARDHOLDER SIGNATURE]{.underline}**

By signing this application, I acknowledge I have read the Citibank^®^
Government Services Travel Card Program *Cardholder Account Agreement*
and agree to be bound by the terms and conditions as set forth in the
Agreement.

\*Cardholder Signature Date

**SECTION VI [AUTHORIZATION PARAMETERS -- COMPLETED BY
AOPC]{.underline}**

\(14\) Dollars per Cycle Limit (Card Limit) \$: (16) ATM Access: Y N
Cycle % \_\_\_

\(15\) Dollars per Transaction Limit \$: (17) Number of Transactions:
Cycle: Daily: [\_\_\_\_\_]{.underline}

## SECTION VII (18) [AGENCY/ORGANIZATION PROGRAM COORDINATOR SIGNATURE AND PHONE NUMBER]{.underline}

\*Approving Agency/Organization Program Coordinator's Signature

\*Date\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\*Approving Agency/Organization Program Coordinator's Business Phone
Number (with area code or country code)

\*Approving Agency/Organization Program Coordinator's Fax Phone Number
(with area code or country code)

*CB004.C --- 04/12/05* \***Asterisked fields must be completed prior to
submission.**

**Numbers in parentheses correspond to numbers on guide sheet on next
page.**

© 2004 Citicorp. All rights reserved.

CITIBANK, CITIGROUP and the Umbrella Device are trademarks and service
marks of Citicorp or its affiliates and are used and registered
throughout the world.

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**GUIDE TO**

**CITIBANK**^®^ **GOVERNMENT TRAVEL CARD (INDIVIDUALLY BILLED ACCOUNT)
SETUP FORM**

**Form for requesting a new individually billed Travel Card.**

> **[IMPORTANT INFORMATION]{.underline}** **about opening a new
> Citibank**^®^ **Government Travel Card account:**
>
> To help the United States Government fight terrorism and money
> laundering, Federal law requires us to obtain, verify, and record
> information that identifies each person that opens an account. What
> this means for you: when you open an account, we will ask for your
> name, a street address, date of birth, and an identification number,
> such as a Social Security Number, that Federal law requires us to
> obtain. We may also ask to see your driver\'s license or other
> identifying documents that will allow us to identify you. We
> appreciate your cooperation.

**Section I -- Instructions**

##### Section II - Reporting Parameters

1.  **Reporting Hierarchy:** Completed by AOPC.

2.  **Processing Unit ID#:** Completed by AOPC.

##### Section III - Plastic Type

3.  **Plastic Type**: Already marked.

#### Section IV - Cardholder Information

4.  **Name of Cardholder:** Full name of Cardholder -- First, Middle
    Initial and Last.

5.  **Agency/Organization Name:** Name of Agency.

6.  **4th Line Embossing:** To be completed by AOPC.

7.  **Home Mailing Street Address:** Your home mailing street address
    line 1 (maximum 36 characters). PO Boxes are not allowed.

8.  **Social Security Number:** Used for card activation. Must be the
    Cardholder's complete nine-digit Social Security Number.

9.  **Business Mailing Address:** Work address.

10. **Verification Information:** Identification code requested from the
    Cardholder when he/she contacts Citibank Customer Service for
    assistance. Mother's maiden name is required.

11. **E-mail Address:** Business e-mail address.

12. **Date of Birth:** Cardholder's date of birth. Enter information in
    mm/dd/yy format.

#### 

##### Section V - Cardholder Signature

#### 13. Cardholder signature required: Cardholder must sign the application.

**(a)** Employees must first read the Department's policies and
procedures related to the use of the Citibank

####  government travel card procedures which can be found at:

####  <http://www.osec.doc.gov/oas/travel/Citibank_Travel_Card_Excerpt.pdf> . 

**(b)** Employees must complete the cardholder on-line training which
can be found at

####  <http://www.corporateservices.noaa.gov/~finance/CITI.html>. 

#### (c) Employees must complete and sign the attached Employee Acknowledgement Statement which certifies

that the employee has read and understands the Department's policies and
procedures related to the use of the Citibank

government travel card procedures. Employees must also record the date
the training was completed on the Employee

Acknowledgement Statement.

> **(d)** After reading Section V of the travel card application,
> employees must sign and date the application which certifies that
>
> he/she understands the terms and conditions for issuance and use of
> the travel card.
>
> **(e)** Employees should retain this application package, with the
> original signatures, for his/hers records and fax a

copy of the completed and signed travel card application, a completed
and signed Employee Acknowledgement

Statement, and a copy of the training certificate showing completion of
the training, to their respective AOPC below:

> **Approving Agency/Organization Program Coordinator\'s Signature and
> Phone Number:**

(a) All line and staff offices, other than NMFS and NWS, will call
    301-444-2107 for assistance,

> and fax applications to 301-413-3066.

(b) NMFS employees will call 301-713-1364, x194 for assistance, and fax
    applications to 301-713-2258.

(c) NWS employees will call 301-713-0420, x104 for assistance, and fax
    applications to 301-608-0850; back-up

> APC: 301-713-0720 X112.

#### 

#### Section VI - Authorization Parameters -- #s 14, 15, 16, and 17 to be completed by AOPC. Purchase limits are automatically set at \$3,000 with a 20% cash limit. If a different credit limit is required, approving officials must indicate the monthly purchase limit in dollar amount in block #14 and the monthly cash limit by percentage in block #16. 

##### Section VII - A/OPC Signature

> **18. Approving Agency/Organization Program Coordinator\'s Signature
> and Phone Number:** Program Coordinator must date and sign for
> approval. The AOPC's business phone and fax number is also requested.\
> *CB004.C --- 04/12/05*
>
> © 2004 Citicorp. All rights reserved.

**U. S. DEPARTMENT OF COMMERCE**

**EMPLOYEE ACKNOWLEDGMENT STATEMENT AND**

**APPROVING OFFICIAL CERTIFICATION STATEMENT**

I certify that I (1) have received, read and understand the policies and
procedures prescribed by the [DOC Travel Handbook]{.underline} issued by
the Director of Administrative Services, pertaining to the Citibank
Government Travel Card Program; (2) will abide by such policies,
procedures, and on-line training as issued by the Department, my
bureau/operating unit and the contractor/card issuer concerning the use
of the card issued to me; (3) acknowledge that the card is to be used
**[only]{.underline}** for expenses incurred incident to officially
authorized Government travel; and (4) agree to pay my travel card
account in full, upon receipt of my billing statement, or no later than
25 calendar days from the closing date on the statement.

(1) \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

> Employee Signature and Date
>
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Name (Type or Print)

> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Title

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Organization and Bureau

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Date On-Line Training Course was completed

(2) \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Approving Official/Supervisor Signature and Date

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Name (Type or Print)

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Title

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Telephone Number

**[NOTE TO EMPLOYEE]{.underline}**: Your Citibank Government travel card
application **will not be processed** unless accompanied by this
completed and signed form. In addition, you **must complete** the
Citibank Travel Card On-line Training which can be found at the
following web site:
<http://www.corporateservices.noaa.gov/~finance/CITI.html>

**[NOTE TO APPROVING OFFICIAL/SUPERVISOR]{.underline}**: Your signature
certifies that this employee is authorized to obtain the Citibank
Government travel card. You will be notified of any inappropriate
charges or if the employee\'s account becomes delinquent.