appendix a - Middlesex

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APPENDIX A
To Policy 4-100
MIDDLESEX-LONDON HEALTH UNIT
1L
CORPORATE PURCHASE CARD
UNIT
REQUEST FORM
PART I: EMPLO VEE INFORM
4 TION
1
Name (as it will appear on card):
Team/Service Area:
Number: 663
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53 17 X
State principal use of card:
PART II: CREDIT LIMITS
Charge all purchases to budget account #:
Date
$ Per
Transaction
$
Per Month
Manager/Director
Approval
Financial Services
Approval
2.
3.
PART III: CARD DETAILS (Financial Services Use Only)
Card Number:
Issue Date:
Expiry Date:
PART IV: LOST, STOLEN, CANCELLED, RETURNED, DAMAGED CARDS
Date Reported/Returned to Financial Services:
Reason Reported/Returned:
Action taken by Financial Services:
Employee’s Signature
Finance & Operations Director’s Signature
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APPENDIX B
To Policy 4-100
AlL
PURCHASE CARD PROGRAM
HEALTH
UNIT
Lost Receipt Form
MIDDLESEX-LONDON
This is to acknowledge that I have lost or misplaced a receipt related to a purchase that I charged to the corporate
purchase card. I (certify) that the purchase detailed below was an eligible and appropriate business expense.
Name
of
cardholder:
Card number:
Date of purchase:
Name of merchant:
Description of item:
Amount of purchase:
Reason for purchase:
Signature of Employee
Date
Signature of immediate supervisor
Date
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APPENDIX C
To Policy 4-100
PURCHASE CARD PROGRAM
Dispute Form
41L
MIDDLSEX-LON DON
HEALTH
UNIT
Date submitted:
Company name:
Company address:
Cardholder name:
Card number:
Cardholder phone number:
Date of disputed purchase:
Amount of disputed purchase:
Name of merchant:
Check one:
Credit not posted (attach credit slip)
Duplicate posting
Erroneous amount (attach sales receipt)
Photo requestlunrecognized charge
Fax completed form to:
US Bank Canada Commercial Card Centre
Fax No: 416-974-4711
Deliver copy of completed form to:
MLHU Financial Services
rd
50 King St. West, 3
Floor
London, ON
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banque.
bank
Canada
VISAS PURCHASING CARD
Employee Card Ap
CARTE VISA’ ACHATS
Demande de carte d’emoloyé
lication
Account Number (For Bank Use 0174’)
Numero do compte (Reserve ala Ban quo)
LI Issue Plastics / Emettre une carte
0
English/Anglais
0 Do Not Issue Plastics / Ne
LI
Français/French
pas
emettre de carte
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5 I 1 I 61
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loan (for Bank Use OnIy/Resen’e ala Ban quo
st,uctlonslNotes/directives addltlonnelles
o_0__0
Complete ALL information Fields Below Unless Indicated Otherwise
Fni imir TflI IS les renseianements demncIes ni-deqsni q
if in1itinn flnntrirA
EMPLOYEE INFORMATION / DONNEES SUR LEMPLOYE
First Name I Prenom
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Initial/Initiate
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Birthdate (MM-DD-YYYY)!
Date de naissance (JJ-MM-AAAA)
Last Name / Nom
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Not to exceed 19 characters in lengtMdmit a dix neut characters en total
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Embossing! Embossage
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et Adresse Professionnelle
Company Name and Business Address I Raison sociale
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Accounting Code I Code comptable
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City / Ville
Province
Home Phone! Tel. au domicile
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Employee No. I Node remploye(e)
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Monthly Credit Limit
Limite de credit mensuelle
Password I Mot de Passe
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Postal Code I Code postal
ill
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Business Phone / Tel. au bureau
Single Transaction Limit
Umite par operation
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Cash Advance%
% avarice de fonds
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III
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UNIT INFORMATION / DONNEES SUB LUNITE
Corporate Billing Information
Company Number Bank Assi,ed
Numero d’entreprise attribué par Ia Banque
Division (Numeric)
Division (numerique)
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11111
TBR and DEF Reporting
Unit (Nxneric)
Unit (Numeric)
Unite (numenque)
Unite (numerique)
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Department (Numeric)
Service (numenque)
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Unit (Numeric)
Unite (numerique)
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hub
Unit (Numeric /
Unite (numerlque)
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Unit (Numeric
Unite (numerique
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COMPANY AUTHORIZATION? AUTORISATION DE LENTREPRISE
Employee Signature
Signature de I’employé (e)
08)30/2010
Date
Approving Managers Signature
Signature du directeur autorisO (e)
Date
Plan Administrator Signature
Signature de radministrateur du pmgramme
Date