Citibank Government Travel Card (Individually …

Citibank Government Travel card (Individually billed account ) Setup FormCB004 Government Travel Set Up Formpage 1 of 41010324 09/12*Asterisked fields must be completed prior to in parentheses correspond to numbers on guide sheet on next : This form should be completed by the Agency/Organization Program Coordinator with the required information input from the I: Instructions (please also see Important Information at the top of page 3.)1. To add a new account , Cardholder completes Section IV and signs in Section VI, AOPC completes Sections II, III, and V, then signs in Section Maintain a copy in the Cardholder and Agency/Organization Program Coordinator s Fax completed form to 605-357-2092 or mail to Citibank Government Services, Box 6125, Sioux Falls, SD II: Reporting Parameters*Reporting Hierarchy: (1) _____ _____ _____ _____ _____ _____ _____*Processing Unit ID#: (2) _____ (maximum 5 characters)Section III: *Plastic Type (Please check one of the following) Government Standard Quasi-Generic GenericSection IV: card Holder Information (Please Print)(4) _____ _____ _____*First Name of Cardholder *Middle Initial *Last Name (maximum 20 characters)(5) _____ ( _____) _____- _____*Agency/Organization Name (maximum 24 characters) *Home Phone(6) _____ ( _____) _

Citibank® Government Travel Card (Individually Billed Account) Setup Form CB004 Government Travel Set Up Form page 1 of 4 1010324 09/12 *Asterisked fields must be completed prior to submission.

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